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COPYRIGHT.    1022 



Copyrigbl,  Ureal  Urltaiii.     All   Rights  Reserved 


PRINTED   IN    US.  A. 


F.    A.     DAVIS    COMPANY 



W.  WAYNE  BABCOCK,  A.M.,  M.D., 

Professor  of  Surgery,  Temple  University  Medical  School ;   Surgeon  in  Chief 
to  the  Samaritan  and  Garrctson  Hospitals, 


Professor  of  Orthopedic  Surgery,  University  and  Eellevue  Hospital  Medical  College, 

New  York  City. 

Professor  of  Surgery,  University  of  Colorado  School  of  Medicine, 

Denver,  Colo. 

Professor  of  Surgery,  University  of  Pennsylvania  Graduate  Medical   School, 

Philadelphia,  Pa. 


Professor  of  Gynecology  and  Clinical  Gynecology,  University  of 

Illinois  College  of  Medicine. 

Chicago,  III. 

Assistant  Professor  of  Surgery,  University  of  Pennsylvania  Medical  School, 

Philadelphia,  Pa. 

Clinical  Professor  of  Medicine,  New  York  Polyclinic  Medical  School, 

Xew  York  City. 

Professor  of  Neurology,  New  York  Polyclinic  Medical  School, 

New  York  City. 

Professor  of  Ophthalmology,  University  of  Colorado  School  of  Medicine, 

Denver,  Colo. 


Professor  of  Genitourinary  Surgery,  Illinois  State  University, 

Chicago,  III. 

E.  D.  BONDURANT,  M.D., 
Professor  of  Mental  and  Nervous  Diseases,  University  of  Alabama  School  of  Medicine, 

Mobile,  Ala. 




Professor  of  Pediatrics,  Temple  University  Medical  School ;  Visiting  Physician 

to  the  Philadelphia  Hospital  for  Contagious  Diseases, 

Philadelphia,  Pa. 


Visiting  Physician  to  Home  for  Consumptives,  Chestnut  Hill,  and  Pediatrist 
to  Jewish  Hospital  and  Eagleville  Sanatorium  for  Consumptives, 

Philadelphia,  Pa. 

Professor  of  Physical  Therapeutics,  Temple  University  Medical   School, 

Philadelphia,  Pa. 


Associate  in  Gastrological  Research,  Chemical  Department,  and  Instructor 

in  Medicine,  Jeflferson  Medical  College, 

Philadelphia,  Pa. 

A.  ROBIN,  M.D., 

Bacteriologist  of  the  Wilmington  City  Water  Department;  formerly  Pathologist  and 

Bacteriologist  of  the  Delaware  State  Board  of  Health. 

Wilmington,  Del. 

Professor  of  Rontgenology  and  Radiotherapy,  Temple  University  Medical  School, 

Philadelphia,  Pa. 

Mt.  Vernon,  N.  Y. 

Lecturer  on  Pharmacology,  Temple  University  Medical  School, 

Philadelphia,  Pa. 

F.  LEVISON,  M.D., 

Formerly  Officer  of  Health, 

Copenhagen,  Denmark. 

C.  E.  deM.  SAJOUS,  M.D.,  LL.D.,  Sc.D., 

Professor  of  Endocrinology  in  the  University  of  Pennsylvania  Graduate  Medical 
School  and  Professor  of  Therapeutics  in  Temple  University  Medical  School, 

Philadelphia,  Pa. 

L.  T.  deM.  SAJOUS,  B.S.,  M.D., 

Associate  Professor  of  Pharmacolog>'  in  Temple  University  Medical  School  and  Instructor 

of  Endocrinology  in  the  University  of   Pennsylvania   Graduate  Medical  School, 

Philadelphia,  Pa. 



Rheumatism 1 

Rheumatic  Fever  1 

Symptoms 1 

Complications  3 

Diagnosis    6 

Secondary  Infectious  Arthritis  ....  7 

Acute   Osteomyelitis    7 

Gout     7 

Etiology    7 

Pathology     10 

Prognosis    11 

Treatment    12 

Muscular  Rheumatism  21 

Symptoms     21 

Etiology  and  Pathology  22 

Treatment    2Z 

Gonococcal  (Gonorrheal)  Rheumatism.  26 

Symptoms    26 

Diagnosis  27 

Etiology    27 

Prognosis    27 

Treatment     27 

Rheumatoid  Arthritis.     See  Joints,   Sur- 
gical Diseases  of. 
Rhigolene.     See  Petroleum. 
Rhinitis  and  Other  Nasal  Disorders.    See 

Rhubarb      29 

Preparations  and  Doses    29 

Poisoning  by  Rhubarb   30 

Therapeutics    30 

Rhus    Poisoning.     See   Dermatitis  Vene- 
Ribs,  Diseases  and  Injuries  of.   See  Index. 
Rickets.     See  Bones,  Diseases  of. 
Riga's    Disease.     See    Mouth,    Lips,   and 

Jaws,  Diseases  of. 
Riggs's     Disease;     Pyorrhea     Alveolaris 

(Spongy   Gums)    30 

Definition    30 

Symptoms    30 

Diagnosis    31 

Etiology    31 

Pathology 23 

Treatment 33 

Ringworm.     See  Trichophytosis. 
Rochelle     Salts.       See     Potassium     and 

Sodium  Tartrate. 
Rocky    Mountain    Spotted    Fever    (Tick 

Fever)   35 

Symptoms    36 

Incubation    36 

Fever  36 

Circulation    36 

Eruption    Z7 

Gastrointestinal  Tract   27 

Urinary  Tract    37 


Rocky    Mountain    Spotted    Fever    (Tick 
Fever),  Symptoms   {continued). 

Respiratory  Tract   27 

Nervous  System  27 

Diagnosis    27 

Etiology    38 

Prognosis    38 

Treatment     38 

Rubella   39 

Synonyms     39 

Definition   39 

Period  of  Incubation 39 

Symptoms 40 

Etiology   42 

Complications  and  Sequelae 43 

Prognosis     43 

Treatment    43 

Rubeola.     See  Measles. 

Rue 43 

Preparations  and  Doses 43 

Physiological    Action    44 

Therapeutic   Uses    44 

Saccharin    44 

Physiological   Effects   44 

Poisoning  by  Saccharin  45 

Treatment  of   Poisoning   45 

Therapeutic  Uses  45 

Salicylic     Acid,     The     Salicylates,     and 

Salicin   45 

Preparations  and  Dose   45 

Unofficial    Preparations    47 

Incompatibilities    49 

Modes  of  Administration   49 

Contraindications   52 

Physiological    Action    52 

Untoward  EflFects  and  Poisoning 53 

Treatment  of   Poisoning   54 

Therapeutics    55 

General  Uses  55 

Local    Uses    58 

Saline  Infusion.     See  Infusions,  Saline   .  59 

Salivary  Glands,  Diseases  of   60 

Xerostoma   (Dry  Mouth)    60 

Symptoms 60 

Etiology  and  Pathology  60 

Treatment 60 

Ptyalism   '. 60 

Treatment 60 

Ptyalism    60 

Salivary  Calculus    60 

Treatment    61 

Tumors  of  the  Salivarv  Glands   61 

Cvsts  ". 61 

Tumors  of  the  Parotid    61 

Tumors  of  the  Maxillary  Gland   ....  61 

Parotitis    62 

Definitions    62 





Salivary    Glands,    Diseases   of,    Parotitis 

Traumatic   Parotitis    62 

Infectious  Parotitis   62 

1.  Mumps   62 

Incubation    63 

Symptoms    63 

Diagnosis    65 

Etiology   65 

Pathology    65 

Complications  and  Sequelae   .  .  65 

Prognosis   67 

Treatment    67 

2.  Metastatic  or  Symptomatic  Par- 

otitis      68 

Symptoms    68 

Pathology    68 

Prognosis   69 

Treatment    69 

Salol.     See  Salicylic  Acid. 

Salophen    69 

Dose  and  Physiological  Action    69 

Therapeutics    69 

Salpingitis.     See   Ovaries  and   Fallopian 

Tubes,   Diseases  of. 
Salt.     See  Sodium. 
Salvarsan.        See      Dioxydiamidoarseno- 


Sandalwood  and  Oil  of  Sandalwood....  70 

Physiological  Action  and  Dose    70 

Therapeutics    70 

Sanguinaria   70 

Preparations  and  Doses   70 

Physiological   Action    71 

Treatment  of  Poisoning  71 

Therapeutic  Action  71 

Santonica  and   Santonin    71 

Preparations  and   Doses   71 

Physiological    Action    71 

Poisoning  by   Santonin    71 

Therapeutic   Uses    72 

Sapremia.      See    Wounds,     Septic,    and 

Sarcoma.     See  Cancer. 

Sarsaparilla    72 

Preparations  and  Doses   72 

Therapeutic  Uses 72 

Scabies    73 

Definition    73 

Symptoms    73 

Etiology    73 

Treatment   73 

Scammonia   74 

Preparations  and  Doses  74 

Physiological   Action    74 

Therapeutic  Uses   74 

Scarlet  Fever    75 

Definition     75 

Symptoms    75 

Ordinary  Tvpe   75 

Mild  Type  " 77 

Severe  Type    78 

Malignant  Type  78 

Surgical   Scarlet   Fever   79 

Diagnosis  and  Etiology   79 

Transmission    82 

Period  of  Incubation   83 


Scarlet    Fever,    Diagnosis    and    Etiology 

Period  of  Infection  84 

Pathology    84 

Complications  and  Sequelae   84 

Angina    84 

Otitis 85 

Adenitis   and   Cellulitis    85 

Joint  Lesions   85 

Nephritis     85 

Pneumonia  86 

Endocarditis  and   Pericarditis   ....  86 

Nervous  Symptoms   86 

Serous  Membranous  Involvement.  86 

Superficial   Gangrene    86 

Prognosis    86 

Prophylaxis    87 

Treatment   89 

Schlammfieber   94 

Sciatica.      See    Nerves,    Peripheral,   Dis- 
eases of. 

Scleroderma    94 

Definition    94 

Varieties    94 

Symptoms    94 

Diagnosis    94 

Etiology    95 

Prognosis   95 

Treatment   95 

Sclerosis.     See  Index. 
Scoliosis.     See   Spine,   Diseases   and   In- 
juries of. 

Scoparius  and  Sparteine  95 

Preparations  and  Doses   96 

Physiological    Action    96 

Therapeutic  Uses   97 

Scopolamine   (Hyoscine)   and  Scopola  .  .  98 

Preparations  and  Dose    99 

Incompatibilities    99 

Modes  of  Administration  99 

Physiological   Action    99 

Absorption   and  Elimination    100 

Untoward  Effects  and   Poisoning   ....  100 

Treatment  of  Poisoning   101 

Therapeutics    102 

As  Sedative  to  the  Central  Nervous 

System    102 

As   Mydriatic  and  Cycloplegic   103 

Morphine-Scopolamine   Anesthesia    . . .  104 
Morphine-Scopolamine      Preliminary 

to   Inhalation   Anesthesia    . .  105 
Morphine-Scopolamine      Preliminary 
to   Local   and    Spinal   Anal- 
gesia      105 

Morphine-Scopolamine  in  Obstetrics.  106 

Scorbutus   108 

Symptoms    108 

Diagnosis    109 

Etiology    109 

Pathology    109 

Prognosis    109 

Treatment    109 

Scorbutus,      Infantile.        See      Infantile 

Scrofula.     See  various  forms  of  Tuber- 




Scrofuloderma.       See     Tuberculosis     of 
the  Skin. 

Seasickness     1 10 

Definition  and   Synonyms   110 

Symptomatology    110 

Complications  and  Sequelae    Ill 

Etiology Ill 

Prognosis    113 

Prophylaxis   113 

Treatment    1 14 

Senega 115 

Preparations  and   Doses   115 

Physiological    Action    115 

Therapeutic  Uses 116 

Sepsis,  Septic  Fever,  Septic  Infection, 
Septic  Poisoning,  Septi- 
cemia. See  Wounds,  Septic. 
Septum,  Diseases  of.  See  Nose  and 
Nasopharynx,  Diseases  of. 
Sera.  See  Diseases  in  which  these  are 
used ;  also  Hematology. 

Serpentaria 116 

Preparations  and  Doses  117 

Physiological  Action  117 

Therapeutic  Uses  117 

Shingles.     See  Herpes  Zoster. 

Shock 117 

Definition    117 

Symptoms    117 

Delayed  Shock  118 

Shell    Shock    118 

Etiology  and  Pathology  119 

Kinetic    Theory    121 

Prophylaxis    122 

Anoci-Association    122 

Treatment    124 

Electrical    Shock    127 

Treatment    127 

Silver 128 

Preparations   and   Doses    128 

Incompatibilities   130 

Modes    of    Administration    130 

Physiological    Action    130 

Poisoning   " 132 

Acute  Poisoning 132 

Treatment  of  Acute  Poisoning  ....  133 

Chronic  Poisoning  133 

Treatment  of  Chronic  Poisoning  . .  134 

Therapeutics    134 

Gastrointestinal    Disorders    134 

Nervous   Disorders    136 

Surgical    Disorders    136 

Disorders  of  the  Respiratory  Tract  137 

Ophthalmic   Disorders    138 

Cutaneous   Disorders    139 

Venereal    Disorders    139 

Removal  of  Silver  Stains   140 

'Sinuses,    Nasal    Accessory;    Diseases   of.  141 
Maxillary  Sinus  or  Antrum  of  High- 
more  141 

Inflammatory  Disorders 141 

Acute    Inflammation    141 

Chronic     Infiammation    or    Em- 
pyema      142 

Treatment    143 

Tumors    of    the    Maxillary    Sinus,    or 

Antrum   147 


Sinuses,  Nasal  Accessory,  Diseases  of. 
Tumors  of  the  Maxillary  Sinus,  or 
Antrum  (continued). 

Polypi    147 

Cysts   147 

Osteoma    147 

Malignant  Tumors 148 

Trea  anent   ,  148 

Frontal  Sinus   148 

Inflannnatory   Disorders    148 

Acute   Inflammation    148 

Chronic    Inflammation    149 

Treatment  149 

Tumors  of  the  Frontal  Sinus   152 

Mucocele    152 

Cysts    153 

Osteoma    153 

Malignant  Tumors   154 

Treatment 154 

Ethmoid   Cells 154 

Inflammatory   Disorders    154 

Acute  Inflammation ;  Acute  Eth- 

moiditis   154 

Chronic  Inflammation  or  Chronic 

Ethmoiditis 155 

Treatment 156 

Tumors  of  the  Ethmoidal  Cells  158 

Benign   Tumors    158 

Malignant   Tumors    158 

Treatment     158 

Sphenoidal   Sinus    159 

Inflammatory   Disorders    159 

Acute   Inflammation    159 

Chronic    Inflammation    or     Em- 
pyema    of     the     Sphenoidal 

Sinus    159 

Treatment     160 

Tumors  of  the  Sphenoidal  Sinus   161 

Benign  Tumors    161 

Malignant  Tumors    161 

Treatment    161 

Skin-Grafting   161 

Reverdin's   Method    161 

Thiersch's  Method  162 

Wolfe-Krause  Method  163 

Skin-periosteum   Bone  Grafts    163 

Caterpillar  Grafting   163 

Tunnel   Grafting    163 

Subcutaneous   Skin-Grafting   163 

Anomalies   in   Grafting    163 

Grafting  from  Dead   Bodies    164 

Sponge-Grafting    164 

Grafting   from   Animals    164 

Histology  and  Pathology  164 

Comparison    of    Methods    164 

Skin,  Surgical  Diseases  of   165 

Sebaceous  Cysts,  or  Wens  165 

Treatment   165 

Furuncle    165 

Diagnosis    165 

Etiology    165 

Treatment     165 

Carbuncle   165 

Doliiiition  165 

Symptoms 166 

Diagnosis  166 

Etiology   166 




Skin,    Surgical    Diseases    of,    Carbuncle 

Prognosis    166 

Treatment     166 

Keratosis   Senilis    167 

Prognosis    167 

Treatment     167 

Calvus   ( Corn )    167 

Treatment    167 

VerrucTe  168 

treatment    lf'8 

Hypertrophicd    Scars    168 

Treatment    168 

Keloid 168 

Symptoms    168 

Diagnosis    , 169 

Etiology  and  Pathology  169 

Prognosis   169 

Treatment 169 

Malignant  Degeneration  of  Scars   . .   169 

Burns 169 

Definition    169 

Varieties    169 

Symptoms 170 

'Local   Effects    170 

Electric  and  X-ray  Burns   171 

Burns  of  Mucous  Surfaces   171 

Constitutional  Effects  1/1 

Complications  172 

Diagnosis     172 

Medicolegal  Aspects  of  Burns 172 

Prognosis    173 

Treatment    173 

Constitutional    173 

Local    174 

Treatment  of  Electrical  Burns  . .    . .    175 

Scar   Tissue  Deformities    176 

Sodium    176 

Preparations  and  Doses 176 

Physiological  Action  180 

Poisoning  by  Sodium  and  Its  Salts   . .   183 

Sodium   Hydroxide   183 

Treatment    of    Poisoning   by    Sod- 
ium Hydroxide 183 

Sodium  Bicarbonate  and  Carbonate  .   184 

Sodium   Chloride   184 

Sodium   Nitrate 184 

Sodium    Sulphate    185 

Sodium  Sulphite  and  Thiosulphate   .    185 

Therapeutics    185 

Gastrointestinal  Disorders 185 

Cutaneous   Disorders    189 

Genitourinary  Disorders   190 

Laryngological  and  Respiratory  Dis- 
orders      190 

Gynecological     and     Puerperal     Dis- 
orders        191 

Constitutional   Disorders   192 

Surgical   Disorders    193 

Chlorides  in   Urine    194 

Saline    Solution    194 

Preparation    194 

Physiological  Action  and  Uses   194 

Modes  of  Administration   195 

(1 )  Saline  Enteroclysis  195 

(2)  Saline  Hypodermoclysis   197 

(3)  Intravenous  Saline  Infusion   .   198 


Sodium,   Saline   Solution,   Modes  of  Ad- 
ministration   (continued). 

(4)    Intraperitoneal     Saline     Infu- 
sion       199 

Contraindications   199 

Other   Solutions    199 

Dawson's    Solution    200 

Locke's   Solution    2(1) 

Ringer-Locke  Solution   200 

Fleig's  Solution    200 

H.  M.  Adier's  Solution   200 

Fischer's   Solution   200 

Spigelia    200 

Preparations  and  Doses  201 

Physiological  Action  20' 

Poisoning  by   Spigelia   201 

Therapeutic   Uses    201 

Spinal   Anesthesia    201 

Physiological   Action    202 

Technique     203 

Solutions    Used    203 

Site  of   Injection    204 

Syringe  and  Needle   205 

Preliminary   Narcotization    206 

Associated  Local   Anesthesia   206 

Induction  and  Management  of  Spinal 

Anesthesia  206 

After-treatment    208 

Indications   and  Advantages  of   Spinal 

Anesthesia  209 

Contraindications    211 

Technical     Difficulties,     Complications, 

and  Sequelae 212 

Position   af  the   Patient    212 

Breaking  of  the  Needle    212 

Lack  of  Anesthesia   212 

Dosage    212 

Circulatory    Depression    212 

Respiratory  Depression 213 

Early  After-effects   213 

Nausea  and  Vomiting   213 

Headache    213 

Backache 213 

Postoperative  Pain 213 

Albuminuria    214 

Remote  After-effects    214 

Injury  to  Nervous  Tissue 214 

Neurotic    Symptoms     214 

Mortality    . . .'. 214 

Sacral   Anesthesia    216 

Spinal  Cord,  Diseases  of  217 

General   Considerations    217 

Infantile      Paralysis;      Polioencephalo- 

myelitis    217 

Synonyms    217 

Definition     217 

Symptoms     218 

Poliomyelitic  Form  220 

Landry's  Form   221 

Bulbar   Form    221 

Encephalitic  Form  221 

Ataxic  Form   221 

Polyneuritic  Form  221 

Meningitic  Form   221 

Abortive  Form   222 

Diagnosis    222 

Etiology 224 




Spinal  Cord,  Diseases  of,  Infantile  Pa- 
ralysis, Polioencephalomyelitis  (con- 

Pathology    225 

Prognosis    225 

Prophylaxis    226 

Treatment    227 

Operative  Treatment    229 

Tenotomy  and  Myotomy  230 

Tendon  Shortening   230 

Tendon    Lengthening    230 

Tenodesis    230 

Extra-articular  Silk  Ligaments  .   230 
Intra-articular  Silk  Ligaments  . .   230 

Arthrodesis 230 

Articular  Transposition   231 

Astragalectomy  231 

Nerve  Anastomosis   231 

Tendon  Transplantation  on  Ten- 
don   231 

Tendon  Transplantation  to  Peri- 
osteum    231 

Elongation     of     Short     Tendons 

by  Means  of  Silk  Sutures  . .  231 

Myelitis  231 

Synonyms  231 

Definition    231 

Symptoms    232 

Diagnosis    -^^ 

Etiology    234 

Pathology   235 

Prognosis    236 

Treatment    236 

Amyotrophic  Lateral  Sclerosis 237 

Definition    237 

Symptoms     237 

Diagnosis    238 

Etiology  238 

Pathology   238 

Prognosis    239 

Treatment    239 

Primary   Lateral   Sclerosis    239 

Synonyms 239 

Definition    239 

Symptoms     239 

Diagnosis    240 

Etiology    240 

Pathology   240 

Prognosis    240 

Treatment   241 

Landry's  Paralysis 242 

Synonyms  242 

Definition    242 

Symptoms    242 

Diagnosis    243 

Etiology   243 

Pathology  244 

Prognosis    244 

Treatment    ■  ■   244 

Hereditary  Ataxia  245 

Synonyms   245 

Definition    245 

Symptoms 245 

Diagnosis    246 

Etiology    246 

Pathology   247 

Prognosis   247 


Spinal    Cord,     Diseases    of,    Hereditary 
Ataxia    (continued). 

Treatment    247 

Ataxic  Paraplegia   248 

Synonyms   248 

Definition    248 

Symptoms 248 

Diagnosis    248 

Etiology    248 

Pathology  249 

Prognosis    249 

Treatment 249 

Syringomyelia   249 

Definition    249 

Symptoms 249 

Diagnosis    251 

Etiology 252 

Pathology   252 

Prognosis    253 

Treatment    253 

Spinal    Cord    and    Nerves,    Injuries    and 

Surgery  of   254 

Nerves,  Injuries  of   254 

Subcutaneous  Nerve  Injuries 254 

Concussion   254 

Contusion 254 

Pressure  Paralysis  254 

Stretching  and  Laceration 254 

Displacement    255 

Treatment     255 

Open   Nerve   Injuries   256 

Effects  of   Nerve  Division    256 

Process  of  Repair  256 

Symptoms 257 

Treatment 258 

Nerve  Suture  or  Neurorrhaphy     258 

Neuroplasty   259 

Nerve-grafting,   Anastomosis,   or 

Implantation    260 

Tubulization 260 

Peripheral   Nerve  Injuries    261 

Nerve  Stretching  or  Neurectasy  . .   263 
Nerve  Extraction  or  Avulsion  ....   264 

Neurectomy   264 

Neurotomy  264 

Removal    of  the    Gasserian    Gang- 
lion or  Its  Sensory  Roqt  ....   265 
Removal   of   the    Cervical    Sympa- 
thetic      266 

Spinal  Meningitis.     See  Meningitis. 
Spinal    Paralvsis.    Infantile.      See    Spinal 

Cord:   Infantile  Paralysis 
Spinal     Paralysis,     Spastic.       See    Spinal 
Cord  :   Primary  Lateral  Scle- 

Spine,   Diseases  and  Injuries  of    266 

Tuberculosis     of     the     Spine      (Pott's 

Disease;    Spondylitis)     266 

Symptoms  and  Diagnosis   266 

Etiology    269 

Treatment     2()9 

Plaster-of-Paris  Jacket   271 

Management  of  Abscess   273 

b'orcilde  i\eduction  of  Deformity  .   274 

Hibbs's  Operation   274 

Albee's  Bone  Grafts  275 




Spine,    Diseases    and    Injuries    of    (con- 

Scoliosis,    or     Rotary    Lateral     Curva- 
tures    275 

Etiology   276 

Diagnosis    276 

Pathology    278 

Treatment   279 

Abbott's  Method 280 

Spondylitis      Deformans ;      Bechterew's 

Disease  286 

Symptoms 286 

Treatment   286 

Spinal  Localization   286 

Tumors  of  the  Spinal  Cord  287 

Symptoms    287 

Diagnosis    287 

Treatment 287 

Sacrococcygeal  and  Sacroanal  Tumors.  287 
Congenital  Deformities  of  the  Spine  . .  290 

Myelocele  or  Rachischisis   290 

Spina  Bifida    290 

Prognosis    291 

Treatment    291 

Technique    of    Excision    of    the 

Sac 291 

Wounds  and   Injuries  of  the  Spine    . .  293 
Gunshot  and  Punctured  Wounds  . . .  293 

Meningomyelorrhaphy    294 

Sprain  and  Dislocation 294 

Symptoms 294 

Dislocation  of  a  Vertebra  295 

Treatment   295 

Bed-sores  295 

Treatment    296 

Sacroiliac  Disease   296 

Treatment    296 

Disorders  of  the  Coccyx  297 

Coccygodynia   297 

Laminectomy    297 

Spine,   Dislocation  of.     See  Dislocations. 
Spirillosis.     See  Relapsing  Fever. 
Spirit  of  Mindererus.     See  Ammonium. 
Splanchnoptosis.       See      Intestines :  Vis- 

Spleen,  Diseases  of  298 

Functions  of  the  Spleen   298 

Anomalies    299 

Movable  or  Wandering  Spleen  300 

Symptoms    300 

Diagnosis    301 

Treatment 301 

Acute    Hyperemia    or    Congestive    En- 

larsrement  of  the  Spleen  ....  301 

Symptoms 302 

Treatment    302 

Abscess  of  the   Spleen  or  Acute  Sup- 
purative  Splenitis    302 

Symptoms    302 

Treatment    303 

Rupture  of  the  Spleen   303 

Symotoms    303 

Treatment    304 

Splenomegalv,     or     Chronic     Enlarged 

Spleen    304 

Syphilitic   Splenomegaly    304 

Tuberculous  Splenomegaly  ■ 305 


Spleen,    Diseases    of,    Splenomegaly,    or 
Chronic  Enlarged  Spleen  (continued). 
Malarial      Splenomegaly      (Ague 

Cake)    305 

Thrombotic    Splenomegaly    305 

Amyloid  Spleen    306 

Miscellaneous    Forms    of    Spleno- 
megaly    306 

Treatment   308 

Splenic    Anemia     308 

Symptoms    309 

Diagnosis  310 

Treatment   311 

Gaucher's  Splenomegaly   312 

Symptoms    312 

Treatment    313 

Splenomegalic    Polycythemia,    or    Ery- 
thremia      313 

Symptoms 313 

Etiology  and  Pathology  314 

Treatment     314 

Perisplenitis :       Capsulitis :       Capsular 

Splenitis    314 

Symptoms 314 

Treatment    315 

Tumors  of  the  Spleen  315 

Symptoms 315 

Treatment    316 

Spleen,     Injuries     of.       See    Abdominal 
Injuries  . 

Squill 316 

Preparations  and  Doses  316 

Phvsiological    Action    317 

Poisoning  by  Squill   317 

Treatment  of  Poisoning  317 

Therapeutic    Uses    317 

Squint.     See   Strabismus. 
St.  Anthony's  Dance.     See  Chorea. 
St.  Anthony's  Fire.     See  Erysipelas. 
St.  Vitus's  Dance.     See  Chorea. 
Staphylorrhaphy.       See     Surgical     Ana- 
plasty,   or    Plastic    Surgery : 
Cleft  Palate. 
Status  Lymphaticus.     See  Thymus,  Lym- 
phaticus,    and    Mediastinum. 
Diseases  of. 

Sterilization  and  Disinfection   318 

Thermal    Sterilization    318 

Mechanical  Sterilization 320 

Chemical   Sterilization    320 

Practical    Uses    of    Chemical    Disin- 
fectants     320 

Disinfection  of  Surgeon's   Hands.  320 
Disinfection      of      the      Operative 

Field 321 

Sterilization     of     Surgical     Para- 
phernalia      321 

Disinfection     of     Bed     and     Body 

Clothing  321 

Disinfection  of  Bath  Water 322 

Disinfection   of   Feces,   Urine,   and 

Sputum    322 

Disinfection  of  the  Sickroom   322 

Disinfection  of  Passenger  Cars  . .  .  323 

Disinfection  of  Books   323 

Stillingia 323 

Preparations  and  Doses  . .  = 323 




Stillingia  (continued). 

Physiological   Action 323 

Therapeutic  Uses 324 

Stokes-Adams   Disease.     See   Heart   and 
Pericardium  :  Heart-block. 

Stomach   Cancer  of 324 

Etiology 324 

Symptomatology  and  Diagnosis   324 

Laboratory  Diagnosis   326 

X-ray  Examination   328 

Treatment   329 

Stomach,  Diseases  of  330 

Gastric  Neuroses   330 

Synonyms  330 

General   Considerations    330 

Neurotic  Secretory  Conditions 330 

Hyperacidity    330 

Etiology   330 

Symptoms    330 

Diagnosis  331 

Prognosis    331 

Treatment   331 

Subacidity  and  .\nacidity   333 

Etiology 333 

Symptoms    333 

Diagnosis    333 

Prognosis    333 

Treatment 333 

Heterochylia   335 

Treatment    335 

Gastromyxorrhea   335 

Etiology    335 

Symptoms    335 

Diagnosis    335 

Treatment     335 

Neurotic   Sensory   Disturbances    336 

Hyperesthesia   Gastrica    336 

Etiology    336 

Symptoms    336 

Diagnosis    336 

Treatment   336 

Gastralgia   Nervosa    337 

Etiology    337 

Symptoms 337 

Diagnosis    337 

Treatment    337 

Neurasthenia  Gastrica   338 

Polysymptomatic   Neurosis  or   Nerv- 
ous Dyspepsia   338 

Etiology  338 

Symptoms    338 

Diagnosis    339 

Prognosis    339 

Treatment 339 

Bulimia  340 

Parorexia   34;) 

Polyphagia  340 

Akoria  341 

Gastralgokcnosis 341 

Anorexia  Nervosa   341 

Sitophobia    341 

Disturbances  of  Gastric  Motility 341 

Myasthenia     Gastrica     and     Gastric 

Atony 341 

Etiology    341 

Symptoms  and  Diagnosis  342 

Prognosis    343 

Stomach,    Diseases    of,    Disturbances    of 
Gastric   Motility,    Myasthenia    Gastrica 
and  Gastric  Atony   {continued). 

Treatment 343 

Secondary   Gastric   Dilatation    344 

Etiology   ■ 344 

Symptoms    345 

Diagnosis    345 

Prognosis    346 

Treatment 346 

Acute  Postoperative  Dilatation  of 
the  Stomach  and  Duo- 
denum      346 

Etiology   346 

Symptoms  and  Diagnosis   346 

Prognosis    347 

Treatment   348 

Gastropolyasthenia    349 

Symptoms  and  Etiology    349 

Diagnosis    350 

Prognosis    350 

Treatment   350 

Cardiospasm    350 

Etiology    350 

Symptoms    351 

Diagnosis    351 

Prognosis    351 

Treatment     351 

Gastrospasm      ( Pseudo      Hour-glass 

Contraction)     352 

Diagnosis    352 

Treatment   352 

Pylorospasm    352 

Etiology    352 

Symptoms   352 

Diagnosis    352 

Treatment    352 

Nervous   Hypermotility    353 

Etiology    353 

Symptoms 353 

Diagnosis    353 

Prognosis    353 

Treatment    353 

Regurgitations    354 

Symptoms 354 

Prognosis    354 

Treatment     354 

Merycism    354 

Symptoms 354 

Treatment    354 

Eructatio   Nervosa    (Aerophagia)    ..   355 

Symptoms    355 

Diagnosis    355 

Treatment    355 

Singultus  Gastrica  Nervosa  (Hic- 
cough )   355 

Vomitus  Nervosus  355 

Varieties  355 

Symptoms 356 

liiagnosis    356 

Treatment 356 

Pneumatosis     357 

Symptoms  and   Diagnosis   357 

Treatment 357 

Peristaltic    Unrest    357 

Symptoms    357 

Diagnosis    357 




Stomach,  Diseases  of.  Disturbances  of 
Gastric  Motility,  Peristaltic  Unrest 

Treatment    357 

Antiperistaltic  Unrest, 358 

Pyloric    incontinence    358 

Symptoms  and   Diagnosis   358 

Treatment    358 

Duodenal  Regurgitation  Due  to  I'"atty 

Foods  358 

Symptoms     358 

Diagnosis    3^8 

Treatment    359 

Acute  Gastritis   359 

Acute  Catarrhal  Gastritis  (Simple 
Gastritis,  Acute  Indiges- 
tion)       359 

Etiology   359 

Pathology   359 

Symptoms 360 

Diagnosis     360 

Treatment    361 

Acute  Suppurative  Gastritis  (Phleg- 
monous     Gastritis,      Gastric 

Abscess )    362 

Etiology 362 

Pathology    362 

Symptoms 362 

Diagnosis    363 

Treatment    363 

Infectious  Gastritis   363 

Toxic  Gastritis  363 

Etiology    363 

Pathology    363 

Symptoms     363 

Diagnosis    364 

Treatment     364 

Antidotes   364 

Chronic  Gastritis    364 

Varieties    364 

Etiology   365 

Pathology   365 

Symptoms 366 

Complications    367 

Diagnosis     367 

Gastric  Neuroses   367 

Gastric  Ulcer  368 

Gastric  Cancer   368 

Amyloid      Degeneration     of      the 

Stomach    368 

Prognosis   368 

Treatment    368 

Surgical    373 

Gastric  and  Duodenal  Ulcer 373 

Etiology   373 

Pathology   373 

Symptoms    374 

Special      Features      of      Duodenal 

Ulcer  3/6 

Diagnosis    377 

Differential    Diagnosis    378 

Gastralgia    378 

Carcinoma    378 

Hyperchlorhydria    and    Gastrosuc- 

corrhea   37S 

Hemorrhagic  and  Other  Forms  of 

Gastritis    379 


Stomach,  Diseases  of.  Gastric  and  Duod- 
enal Ulcer,  Differential  Diagnosis  (con- 

Pylorospasm    379 

Appendicitis    379 

Hyperemesis  of  Pregnancy 380 

Uremia    380 

Biliary    Conditions     380 

Renal'  Colic    380 

Arteriosclerosis   381 

Spinal  and  Other  Diseases   381 

Post-ulcer    Conditions    381 

Prognosis   381 

Prophylaxis     382 

Treatment    382 

Diet  382 

Medicinal   Treatment    385 

Special  Treatment  of  Symptoms   .   387 

Sippy's  Treatment   388 

Surgical  Treatment  388 

Syphilis  of  the  Stomach 391 

Pathology 391 

Symptoms  and  Diagnosis 391 

Treatment    392 

Tuberculosis  of  the   Stomach    392 

Etiology   392 

Pathology 392 

S3-mptoms  and  Diagnosis   393 

Treatment 393 

Pseudomembranous  Gastritis   394 

Benign  Tumors  of  the   Stomach    394 

Pathology  394 

Adenomata 394 

Papillomata    394 

Myomata   and   Fibromyomata    ....   394 

Lipomata    394 

Myxomata    394 

Lymphadenomata   394 

Retention   Cysts    395 

Gastroliths  and  Foreign   Bodies   . .   395 

Hypertrophy  of  the  Pylorus 395 

Symptoms  and  Diagnosis   395 

Treatment 396 

Stomach,  Injuries  and  Surgical  Diseases 
of.     See   Abdomen.   Surgery 
of,  and  Abdominal   Injuries. 
Stomatitis.     See  Mouth,  Diseases  of. 

Stovaine    396 

Physiological    Action    397 

Poisoning    397 

Therapeutics   397 

Strabismus    398 

Definition  398 

Symptoms    398 

Varieties     400 

Diagnosis    401 

Prognosis    493 

Treatment    ' 403 

After-treatment 406 

Stramonium    406 

Preparations  and  Doses  406 

Physiological    Action    407 

Therapeutic  Uses    407 

Strontium    407 

Preparations  and   Doses    407 

Physiological    Action    407 

Therapeutics    408 



Strontium,  Therapeutics    (continued). 
Acute     Rheumatism     and     Constitu- 
tional  Disorders   408 

Nephritis    408 

Cardiovascular    Disorders     409 

Gastrointestinal    Disorders    409 

Nervous   Disorders    409 

Cutaneous   Disorders    409 

Strophanthus 409 

Preparations  and   Doses    409 

Physiological  Action  410 

Untoward  Effects  and  Poisoning  411 

Therapeutics    411 

Struma.     See  Goiter. 
Strychnine.     See   Nux  Vomica. 
Stye.      See    Eyelids,    Diseases    of :  Hor- 
Stypticin.     See  Cotarnine. 
Styptol.     See  Cotarnine. 
Subphrenic    Abscess.      See    Liver,    Dis- 
eases of. 
Suggestion-therapy ;    Psychotherapy ; 

Hypnotherapy  (Hypnotism).  414 

Psychotherapy    414 

Psychotherapeutic   Technique    415 

Hypnotherapy    ("Hypnotism")    418 

Technique 419 

Therapeusis    420 

Sulphonal 421 

Modes  of  Administration   421 

Physiological    Action    422 

Contraindications   422 

Untoward   Effects   and   Poisoning    ....  422 

Acute   Sulphonal  Poisoning   423 

Treatment  of  Acute  Sulphonal  Pois- 
oning    423 

Chronic  Sulphonal  Poisoning 424 

Treatment     of     Chronic      Sulphonal 

Poisoning    425 

Therapeutics    425 

Sulphur  426 

Preparations  and   Doses    427 

Physiological  Action  427 

Untoward  Effects  and  Poisoning 428 

Treatment    42<S 

Therapeutics    428 

Gastrointestinal     and     Constitutional 

Disorders    428 

Respiratory   Disorders    429 

Chlorosis  430 

Cutaneous    Disorders    430 

As  Insecticide  431 

Sulphuric   Acid    431 

Preparations  and  Doses  431 

Physiological   Action    431 

Treatment  of  Poisoning   431 

Tlierapeutic  Uses   432 

Sulphurous   Acid    432 

Action  and  Uses   432 

Sumbul    433 

Preparations  and   Doses    433 

Physiological    Action    433 

Therapeutic   Uses    433 

Sunstroke.     See  Heat  Exhaustion. 
Suprarenal    Capsules.    Duscases    of.      See 
Adrenals,  Diseases  of. 


Suprarenal  Organotherapy.     See  Animal 


Surgical  Anaplasty,  or   Plastic   Surgery..  433 

General   Considerations    433 

General  Technique 434 

Deformities   of   the   Lips    434 

Varieties   434 

Median  Harelip   434 

Simple  Unilateral   Harelio    434 

Unilateral     Harelip     with     Fissure 

of  the  Bony  Parts  434 

Simple  Bilateral  Harelip  434 

Complicated  Bilateral  Harelip  ....  434 

Treatment    435 

After-treatment      and      Complica- 
tions    435 

Hypertrophy   of   the   Lips    437 

Deformities   Due  to  Injury    437 

Treatment   437 

Everted    Lip    437 

Inverted    Lip     438 

Excision  of  Labial  Cancers   438 

Formation    of    the    Lower    Lip    after 

Complete   Excision 438 

Restoration  of  the  Upper  Lip   439 

Macrostoma    (Large   Mouth )    439 

Treatment   439 

Microstoma  (Congenital  Atresia  Oris).  439 

Treatment   439 

Cleft  Palate  439 

Treatment   439 

Staphylorrhaphy     440 

Uranoplasty   440 

After-treatment    441 

Rhinoplasty    442 

Indian   Method   442 

Italian    Method    442 

Reduction     of     Hump-nose     (Aquiline 

Nose)     443 

Stenosis  of  the  Nose   443 

Paraffin  Injections   (Hydrocarbon  Pro- 
thesis)    443 

Plastic     Surgery    of     the     Ear     (Oto- 
plasty)     443 

Outstanding    Ears     443 

Abnormally    Enlarged    Ear    (Macro- 

tia) 444 

Repair  of  Clefts  and  Fissure  of  the 

Lobule   444 

Enlarged   Lobule    444 

Elongated   Lobule    444 

Shortened  Lobule 444 

Adherent  and   Undeveloped  L(jl)u!c   .  444 

.Sweat-glands,  Diseases  of  the  444 

Anhidrosis    444 

Treatment 444 

Hyperidrosis,  or  Excessive  Sweatin.u   .  445 

Treatment   445 

Bromidrosis   446 

Treatment   446 

Chromidrosis,  or  Colored  Sweat  447 

Treatment 448 

Tumors  of  the   Sweat-glands    448 

Treatment     ' 448 

Svcosis.     See  Hair,    Diseases  of. 
Syni])le])haron.      .See   Eyelids. 
Synovitis.     Sec  Joints. 




Syphilis  44H 

Etiology    and    Symptoms    448 

Incubation  Period  of  Syphilis   449 

Specific  Micro-organism  of   Syphilis.  449 

Primary  Local  Changes  450 

The  Initial  Lesion,  or  Chancre 452 

Varieties  of  Induration   453 

Diagnosis  of   Chancre    454 

Loss  of  Tissue  in  Chancre 454 

Secretion  of   Chancre    455 

Comparative  Frequency  of  Chancre 

and   Chancroid    455 

Complications  of  Chancre 455 

Mixed  Chancre 456 

Phagedenic    Chancre    456 

Infectious    Secretions    in    Syphilis 

and  Infection  456 

Modes  of  Contagion   457 

Duration  of  Chancre   45(S 

Number   of    Chancres    458 

General     Infection,    Constitutional,     or 

Secondary  Syphilis   458 

Diagnosis  458 

Constitutional    Syphilis    458 

Wassermann    Test    458 

Sources  of  Fallacy 458 

General    Adenopathy    459 

The  Roseola    459 

Syphilitic    Prodromes     459 

Pharyngofaucial  Infiltration 460 

The   Papular   Syphilide   460 

Syphilitic   Alopecia    460 

Syphilis   of   the   Nails    460 

Pustules,  Vesicles,  and  Precocious 

Skin-lesions   460 

Special  Mucous  Lesions  460 

Visceral  involvement    461 

Early  Ocular  Syphilis   461 

Early   Osseous   Symptoms    461 

Earlv  Nerve  Involvement  in  Syph- 
ilis       461 

Late    Syphilis,    Sequelar    or    So-called 

Tertiary    Syphilis    462 

The   Tubercular   Syphilide    (Gummy 

Infiltration)    462 

The   Gumma    463 

Late,     or     Sequelar,     Nerve     and 

Brain    Syphilis    463 

Syphilides    464 

Prognosis    465 

Curability  of  Syphilis    466 

When  May  a  Syphilitic  Marry? 466 

Congenital    Syphilis    466 

Acquired   Syphilis  in  Children   466 

Syphilis  Hereditaria  Tarda 467 

Lesions    of    Congenital    Syphilis    . . .  467 

Treatment   468 

New  Remedies    471 

Salvarsan    471 

Method    473 

Technique    473 

Local   Treatment  of   Chancre    473 

Syringomyelia.      See    Spinal    Cord,    Dis- 
eases of. 

Tabes  Dorsal  is   474 

Definition    474 


Talies  Dorsalis   (continued). 

Varieties   474 

Symptoms 475 

Symptomatic   Analysis   477 

The    Reflexes    477 

Pupillary    Symptoms    478 

Optic   Atrophy    479 

Ocular-muscle  Palsies   479 

Ataxia    479 

Tabetic    Crises    480 

Cardiac  Crises    481 

Sensory  Symptoms    481 

Trophic  Symptoms   481 

Vesical,      Rectal,      and      Sexual 

Symptoms 482 

Special    Senses    483 

Diagnosis    483 

Etiology    484 

Pathology   486 

Complications    488 

Prognosis    488 

Treatment   489 

Tachycardia.         See       Heart :     Frequent 

Talipes.     See  Orthopedic  Surgery. 

Tamarind   496 

Action  and  Uses  496 

Tannic  Acid  496 

Preparations  and   Doses    497 

Physiological  Action  497 

Therapeutic  Uses  498 

Tansy 499 

Preparations  and  Doses  499 

Physiological    Action    499 

Poisoning   by   Tansy    499 

Treatment    of    Poisoning    499 

Therapeutic    LTses    499 

Tape-worm.     See  Parasites,  Disease  Due 

Tar 499 

Preparations  and  Doses 500 

Physiological    Action    500 

Poisoning  by  Tar   500 

Treatment     501 

Therapeutics  501 

AfYcctions  of  Mucous  Membranes.  501 

External  Uses 501 

Lysol 502 

Poisoning  by  Lysol   502 

Therapeutics  502 

Pixol    503 

Taraxacum    503 

Preparations  and   Doses    503 

Physiological  Action 503 

Therapeutic   Uses    503 

Tartar  Emetic.     See  Antimony. 
Telangiectasis.     See  Blood-vessels,  Tum- 
ors of. 
Tendons,    Bursse,    and    Fasciae,    Diseases 

of 504 

Diseases  of  the  Tendons  504 

Acute  Tenosynovitis   504 

Symptoms 504 

Palmar  Abscess    504 

Felon,  or  Whitlow    504 

Treatment 504 




Tendons,  Bursae,  and  Fasciae,  Diseases  of, 
Diseases  of  the  Tendons   (continued). 
Chronic  Tenosynovitis,  or  Thecitis..   50^) 

Treatment     505 

Injuries   of   tendons.      Displacement   or 

Dislocation   506 

Treatment     507 

Rupture  507 

Treatment   507 

Wounds  of  Tendons   507 

Treatment 508 

Diseases  of  the  Bursse  503 

Acute   Bursitis    508 

Treatment 508 

Chronic   Bursitis    508 

Housemaid's   Knee    509 

Treatment 509 

Bunion 509 

Treatment 509 

Ganglion   510 

Treatment   510 

Contraction  of  Tendons  and  Fascia   . .   510 

Dupuytren's    Contracture    510 

Treatment    510 

Trigger-finger  511 

Treatment    511 

Tendon   Transplantation    511 

Tetanus   512 

■  Synonyms   •  • 512 

Definition    512 

Symptoms    512 

Diagnosis    514 

Etiology   515 

Bacteriology 517 

Pathology   518 

Prognosis    518 

Treatment    519 

Prophylaxis    525 

Theobromine.     See  Diuretin. 

Theocine 527 

Physiological  Action 527 

Therapeutic  Uses  527 

Thermic    Fever.      See    Heat    Exhaustion 
and  Thermic  Fever. 

Thiocol 5?7 

Preparations  and   Doses    528 

Physiological    Action    528 

Therapeutic   Uses    528 

Thiosinamine    528 

Physiological  Action   528 

Untoward  Effects  and  Poisoning 529 

Therapeutics  529 

Thomsen's  Disease.     See  Muscles :  Myo- 
tonia Congenita. 
Thoracentesis.      See   Chest,    Injuries   and 

Surgical  Disorders  of. 
Thoracic    Duct,   Injuries   of.    See   Chest, 
Injuries    and    Surgical    Dis- 
orders of. 
Thoracoplasty.     See  Chest,   Injuries  and 

Surgical  Disorders  of. 
Thoractomy.      See    Chest,     Injuries    and 

Surgical  Disorders  of. 
Thorax,   Wounds   and    Injuries   of.      See 
Chest,  Injuries  and  Surgical 
Disorders  of. 
Thorium.     See  X-rays  and  Padii'.ri. 


Thread-worms.     See   Parasites  :  Oxyuris 

Thrombosis.     See  Vascular  System,  Sur- 
gical Diseases  of. 
Thrush.      See   Mouth,    Lips,   and   Jaws : 
Parasitic  Stomatitis. 

Thymol    531 

Physiological    Action    531 

Untoward  Effects  and   Poisoning   ....   532 
Treatment  of  Thymol  Poisoning   . .  .   532 

Therapeutics   532 

Internal  and  Systemic  Uses  532 

Local    Uses    533 

Thymus,   Lymphatics,   and   Mediastinum, 

Diseases  of 533 

Functions  of  the  Thymus   533 

Functions  of  the  Lymphatics  533 

Anomalies   of   the   Thymus   and   Lym- 
phatics       534 

Diseases  of  the  Thymus   534 

Enlargement     of    the     Thymus    and 

Lymphatics    535 

Status  Thymicolymphaticus 535 

Symptoms 535 

Thymic   Stridor    535 

Thymic    xA.sthma    535 

Thymic    Death    535 

Thymic   Symptoms    536 

Lymphatic    Symptoms    537 

Pathogenesis  538 

Treatment 538 

Thymectomy  Technique 539 

Prevention  of  Paroxysms   540 

Diseases   of  the   Lymphatics    540 

Lymphadenitis    540 

Lymphangitis 541 

Symptoms 541 

Diagnosis    541 

Etiology   542 

Treatment    542 

Lymphangiectasia ;  Lymphangioma   .   542 

Symptoms    543 

Etiology    543 

Treatment 544 

Tumors  of  the  Lympliatic  System  . .   544 

Treatment 544 

Glandular  Fever 545 

Symptoms 545 

Etiology    545 

Treatment    546 

Mediastinum,  Diseases  of  the   546 

Acute  and  Chronic  Mediastinitis  ....   546 

Symptoms 547 

Acute  Mediastinitis   547 

Chronic    Mediastinitis    547 

Abscess  of  the  Mediastinum  ....   547 
Tuberculous    Mediastinal     Lym- 
phadenitis      548 

Tuberculosis     of    the     Bronchial 

Glands   548 

Diagnosis    549 

Treatment    550 

Tumors  of  the  Mediastinum 551 

Treatment 552 

Th\roi(I  Gland,  Diseases  of  552 

Functions 552 

Hypothyroidia     552 




Thyroid    Gland,    Diseases    of,    Hypothy- 
roidia   {continued) . 

Symptoms 552 

Diagnosis    554 

Etiology    554 

Pathogenesis  555 

Treatment   555 

Myxedema,    or    Progressive    Hypothy- 

roidia  ' 555 

Definition    556 

Symptoms 556 

Diagnosis    558 

Etiology    558 

Treatment   558 

Surgical  Disorders  of  the  Thyroid  Ap- 
paratus      559 

Injuries   559 

Treatment    560 

Surger>'  of  the  Thyroid 560 

Indications    560 

Operative  Precautions   561 

Operative  Technique    562 

Thyroid  Therapy.     See  Animal  Extracts  : 

Thyroid   Gland. 
Thyroidism.        See      Animal      Extracts : 

Thyroid  Gland. 
Thyroiditis.     See  Goiter. 
Thyrotomy.     See   Larynx,   Diseases   and 

Surgery  of. 
Tic  Douloureux.    See  Nerves,  Peripheral, 

Diseases  of. 
Tinea.  See  Parasites,  Diseases  Due  to. 
Tinea  Favosa,  Tonsurans,  Trichophy- 
tina.  .See  Hair,  Diseases  of. 
Tinea  Nodosa.  See  Piedra. 
Tinnitus  Aurium.  See  Internal  Ear.  Dis- 
orders of. 

Tobacco    563 

Physiological  Action  563 

Acute  Poisoning 563 

Chronic    Poisoning    563 

Treatment  of  Acute  Poisonine 564 

Toe,  Hammer-.     See  Orthopedic  Surgery. 
Toe-nails,    Ingrowine.      See    Nails,    Dis- 
eases and  Injury  of. 

Tongue,  Diseases  of  564 

Tongue-tie,  or  Ankyloglossia   564 

Treatment    564 

Lingual  Paoillitis 564 

Treatment    565 

Parenchymatous  Glossitis  565 

Symptoms 565 

Treatment   565 

Chronic  Glossitis   565 

Svmptoms 565 

Treatment   565 

Leucoplakia 566 

Treatment   566 

Eczema  of  the  Tongue 566 

Treatment   566 

Ulceration  of  the  Tongue   566 

Simple    Ulcer    566 

Syphilitic  Ulcer   566 

Tuberculous   Ulcer    567 

Cancerous   Ulcer    567 

Treatment   567 

Tumors   of  the  Tongue    567 


Tongue,     Diseases    of.    Tumors    of    the 
Tongue   {continued) . 

Treatment   567 

Cancer  of  the  Tongue   567 

Symptoms    567 

Etiology    ■ .  568 

Prognosis 568 

Treatment    568 

Butlin's   Technique    568 

Whitehead's  Technique  569 

Kocher's   Technique    569 

After-treatment    569 

Injuries  of  the  Tongue    570 

Treatment   570 

Tongue-tie.     See  Tongue,  Diseases  of. 
Tonsils.     See  Pharynx  and  Tonsils,  Dis- 
eases of. 
Torticollis.     See  Muscles,  Diseases  of. 
Toxemia.     See  Wounds,  Septic. 
Toxic  Foods,  or  Ptomaine  Poisoning  ....   570 

Meat    Poisoning    570 

Bacillus    Enteritidis    570 

Bacillus  Botulinus   571 

Bacillus    Proteus    571 

Bacteria  of   Diseased   Meat    . .   571 

Symptoms 571 

Fish  Poisoning  572 

Symptoms    572 

Shellfish   Poisoning   572 

Symptoms    573 

Milk.  Cream  and  Cheese  Poisoning  .   573 

Symptoms    573 

Mushroom    Poisoning    573 

Symptoms    574 

Treatment  of  Food  Poisoning 574 

Grain  and  Vegetable  Poisoning   ....   575 

Ergot  575 

Chicken-pea   575 

Sprouting    Potatoes    575 

Treatment 575 

Pellagra,  or  Maidism 575 

Pathology    576 

Symptoms 576 

Treatment    576 

Trachoma.       See    Conjunctiva.     Diseases 

Transfusion.        See      Venesection      and 

Traumatic  Neuroses.     See  Vascular  Sys- 
tem, Disorders  of. 
Trematodes.       See     Parasites,     Diseases 
Due  to. 

Tremors    577 

Senile  Tremor 578 

Hysterical   Tremor    578 

Hereditary  or  Family  Tremor 578 

Toxic   Tremor    578 

Infantile  Tremor  578 

Intention  or  \'olitional   Tremor   . .   578 

Etiology   and   Pathogenesis    579 

Treatment 579 

Paralysis     .A.gitans     (Parkinson's  Dis- 
ease;  Shaking  Palsy)    580 

Symptoms     580 

Diagnosis  582 

Etiology,     Pathogenesis,     and     Path- 
ology      582 




Tremors,  Paralysis  Agitans  (Parkinson's 
Disease;   Shaking  Palsy)    (continued). 

Treatment   583 

Multiple    Sclerosis    585 

Synonyms 585 

Definition    585 

Symptoms 585 

Diagnosis    586 

Etiology    586 

Pathology  587 

Prognosis    587 

Treatment 587 

Trichocephalus    Dispar.      See    Parasites, 
Diseases  Due  to. 

Trichophytosis 588 

Symptoms 588 

Etiology    588 

Prognosis    588 

Treatment  588 

Trigger    Finger.      See    Tendons,    Bursse 
and  Fascise,  Diseases  of. 

Trional 589 

Physiological   Action    589 

Poisoning  by  Trional   589 

Treatment   589 

Therapeutic   Uses    590 

Tropacocaine  590 

Physiological  Action  590 

Untoward    Symptoms    590 

Therapeutic    Uses    590 

Trypanosomiasis,   or    Sleeping   Sickness.  591 

Symptoms   591 

Diagnosis    •  • 591 

Prophylaxis    591 

Treatment   592 

Tuberculosis,  Acute 592 

Acute  Miliary  Tuberculosis  593 

Symptoms  and  Diagnosis    593 

General  or  Typhoid  Form   593 

Pulmonary  Form  594 

Meningeal  Form    594 

Diagnosis    595 

Pathology  595 

Treatment  595 

Acute  Pneumonic  Phthisis  596 

Symptoms 596 

Treatment  596 

Tuberculosis,  Chronic  Pulmonary   597 

Symptomatology 597 

Loss   of   Strength    597 

Indigestion    597 

Anorexia    598 

Anemia    598 

Autonomic    Disturbances     598 

Lowered  Blood-pressure    598 

Increased   Pulse  Frequency   598 

Fever    598 

Cough 598 

Expectoration    598 

Hemoptysis    598 

Hoarseness  599 

Pain   599 

Night-sweats   599 

Emaciation  599 

Dyspnea    599 

Diarrhea   599 

Neuritis 599 


Tuberculosis,   Chronic   Pulmonary,Symp- 
tomatologv   (continued). 

Psychical  Changes  599 

Physical    Examination     599 

Inspection 599 

Palpation    601 

Percussion    601 

Auscultation    603 

X-ray  Examination   606 

The  Blood 606 

Sputum :     Microscopic     Examination 

of  607 

Diagnosis  608 

Differential   Diagnosis    609 

Etiology   and    Pathogenesis    609 

Pathology    611 

Prognosis    612 

Treatment    613 

Fresh  Air   613 

Rest    614 

Exercise    614 

Respiratory  Exercises 615 

Diet  615 

Clothing    ■  • . 616 

Bathing  616 

Chest  Compress   617 

Tuberculins  and  Sera    617 

Iodine 619 

Creosote  and  its  Derivatives   620 

Arsenic  and  its  Compounds   620 

Calcium 620 

Thyroid    Gland    620 

Nuclein 620 

Cinnamic   Acid    621 

Mercury    621 

Strychnine 621 

Ichthyol     621 

Camphor    621 

Digitalis 621 

Nitroglycerin    621 

Quinine 621 

Urea 622 

Iron  622 

Other  Drugs    622 

Surgical   Treatment    622 

Artificial   Pneumothorax    : 622 

Chondrotomy     623 

Extra-plcural   Thoracoplasty    623 

Inhalations  623 

Treatment  of  Symptoms  623 

Fever   623 

Night-sweats   623 

Cough    623 

Hemoptysis   623 

Prophylaxis    623 

Tuberculosis   of   the   Serous    Membranes 

and    Skin    625 

Mescntric       Tuberculosis      or      Tabes 

Mesenterica    625 

Symptoms 625 

Diagnosis    625 

Prognosis    626 

Treatment   626 

Tuberculosis  of  the  Myocardium 626 

Treatment   626 

Tul)crculosis  of  the  Skin  626 

Scrofuloderma  626 




Tuberculosis  of  the  Serous  Membranes 
and  Skin,  Tuberculosis  of  the  Skin, 
Scrofuloderma  {c(»iliiiucd }. 

Symptoms 626 

Etiology  and  Pathogenesis  626 

Treatment   627 

True     Tuberculosis     or     Tul)erculosis 

Cutis    627 

Treatment   627 

Tuberculosis  Verruca  Cutis   627 

Symptoms 627 

Treatment    627 

Lupus  Vulgaris 627 

Symptoms     628 

Diagnosis    628 

Etiology  and  Pathology  628 

Prognosis    628 

Treatment   629 

Lupus  Erythematosus  630 

Symptoms 630 

Etiology    631 

Treatment   631 

Turpentine       (Terebene;      Terpin      Hy- 
drate )  632 

Preparations  and   Doses    632 

Physiological   Action    633 

Untoward  Effects  and  Poisoning 633 

Treatment  of   Poisoning   633 

Therapeutics    633 

Twilight  Sleep.    See  Scopolamine. 
Typhlitis.     See  Appendicitis. 

Typhoid   Fever 635 

Symptoms     635 

Varieties  of   Typhoid   Fever    637 

The   Temperature    637 

Chills   638 

The  Skin 638 

Bed-sores    639 

The  Digestive   System   639 

The   Stomach    639 

The    Intestines    639 

Meteorism   639 

Pain   639 

The   Rectum    640 

The  Abdominal   Organs    640 

The  Gall-bladder  640 

The  Spleen 640 

The  Respiratory  System 640 

The  Circulatory  System    640 

Blood-pressure    640 

The  Nervous  System   640 

The   Genitourinary   System    641 

The   Reproductive   Organs    641 

Complications    641 

Perforation    642 

Diagnosis    644 

The  Bordet-Gengou  Reaction    645 

The     Ophhalmic     Reaction     in     Ty- 
phoid      646 

Isolation    of    Typhoid    Bacilli    from 

Body  Fluids 646 

Etiology    647 

Pathology   649 

Histology 650 

The  Blood  in  Typhoid  Fever   650 

Prognosis    651 

Age 651 


Typhoid  Fever,  Prognosis  (continued) . 

Habits    651 

Severity  of  Infection   651 

Complications    651 

Per  f oration   65 1 

Relapse    651 

Treatment 651 

1.  Diet  and  General  Management  . . .  652 

2.  Hydrotherai)y  654 

3.  Medicinal    Treatment    655 

4.  Vaccine  and  Serum  Treatment   . .  656 

5.  Treatment   of    Complications    ....  656 
Treatment  of  Convalescence   657 

The  Public  Health  Aspect  of  Typhoid 

Fever  657 

Purification    of    Water    658 

Filtration   658 

Slow    Sand   Filters    658 

Mechanical    Filters    659 

Chlorine    Gas    660 

Flies  ih  Tj'phoid  P'ever    660 

Prophyla.xis    661 

Typhoid   Vaccination    663 

Paratyphoid   Fever    663 

Symptoms     663 

Complications    664 

Diagnosis    664 

Treatment    664 

Typhoid  Fever  in  Infancy 664 

Typhoid  Fever  in   Early  Childhood    .  .  665 
Typhoid  Fever  in   Later  Childhood    .  .   665 

Typhus  Fever  665 

Definition    665 

Symptoms     665 

Brill's  Disease 666 

Diagnosis    666 

Etiology  and  Pathologv  667 

Prognosis   667 

Prophylaxis    668 

Treatment    668 

Ulcers  and  Varicose  Ulcers.  See  Vas- 
cular System,  Surgical  Dis- 
eases of. 

Uremia    668 

Symptoms    669 

Acute   Uremia    669 

Chronic  Uremia   669 

Diagnosis    670 

Etiology    671 

Treatment   671 

Urea,    Determination   of    672 

Specific  Gravity  Method   672 

Sodium   Hypobromite   Method    672 

Davy's    Method    673 

Benedict's  Method  673 

Folin's    Method    673 

Marshall's  Method    674 

Ureters.      See     Kidneys      and      Ureters. 

Diseases  of. 
Ureters  and  Bladder,  Examination  of. 

Cystoscopy   675 

Varieties  of  Cystoscope   675 

Preparation    of    the    Cystoscope    for 

Use 675 

Preparation  of  the   Patient    676 

General  Anesthesia  676 




Ureters    and    Bladder,    Examination    of, 
Cystoscope    (continued). 

Technique  of  Cystoscopy   676 

Uses  of  Cystoscopy  677 

Ureteral  Catheterizaion   678 

Urinary    Segregation    678 

Urethane 679 

Physiological   Effects    679 

Poisoning  by  Urethane 679 

Treatment  of   Poisoning   679 

Therapeutic   Uses    679 

Urethra.  See  Urinary  and  General  Sys- 
tems, Surgical  Diseases  of. 
Urinalysis.  See  Index  under  titles  of 
various  abnormal  conditions 
of  Urine  :  Albuminuria.  Lac- 
tosuria,  Tyrosinuria,  etc. 
Urinary    and   Genital    Systems,    Surgical 

Diseases  of    679 

Diseases  of  the  Urethra   679 

Anomalies  of  the  Urethra 679 

Congenital  Occlusion 679 

Congenital    Stricture    679 

Urethral   Pouches    679 

Epispadias  680 

Treatment   680 

Hypospadias    680 

Treatment 680 

Injuries  of  the  Urethra    681 

Rupture  of  the  Urethra  681 

Symptoms     681 

Treatment   682 

Foreign    Bodies    and    Calculi    in    the 

Urethra  683 

Symptoms    683 

Diagnosis    683 

Treatment    683 

Gonorrhea    684 

Definition    684 

Symptoms    684 

Acute  Gonococcal  Urethritis   . .  .  684 
Chronic  Gonococcal  Urethritis   .  685 

Diagnosis    685 

Complications    686 

Prophylaxis    686 

Abortive  Treatment    687 

Repressive  Treatment 687 

Treatment  of  Chronic  Gonorrhea  .  691 

Gonorrhea  in   Women    692 

Urethra  693 

Treatment    693 

Vagina    and    Vulva    693 

Symptoms 693 

Treatment    693 

Periurethritis  and  Urethral  Fistula   .  694 

Treatment    694 

Cowpcritis   695 

Treatment     695 

Non-gonorrheal   Urethritis    695 

Symptoms 695 

Diagnosis  695 

Treatment     695 

Stricture  of  the   Urethra   695 

Varieties    696 

Symptoms    696 

Diagnosis    696 

Etiology_ 697 


Urinary  and  Genital  Systems,  Surgical 
Diseases  of,  Diseases  of  the  Urethra, 
Stricture  of  the  Urethra   {continued) . 

Treatment    697 

Dilatation    697 

Urethrotomy    698 

Internal  Urethrotomy 698 

External   Urethrotomy   699 

A.  With    a    Guide — Syme's 
Operation 699 

B.  Without   a    Guide— Peri- 
neal Section  699 

Urethral,       Urinary,      or      Catheter 

Fever   699 

Symptoms  and  Etiology 699 

Acute   Urinary   Septicemia   699 

Chronic  Urinary  Septicemia  ....   700 
Treatment    '. 700 

Chancroid  700 

Definition   700 

Symptoms 700 

Etiology    701 

Diagnosis    701 

Complications    701 

Treatment   702 

Tumors  of  the  Urethra 702 

Treatment   703 

Diseases  of  the  Prostate  703 

Anomalies    703 

Injuries  of  the  Prostate 703 

Etiology   703 

Treatment   703 

Foreign    Bodies    and    Calculi    in    the 

Prostate   704 

Symptoms     704 

Etiology    704 

Diagnosis  704 

Treatment   704 

Acute  Prostatitis   704 

Symptoms 704 

Etiology    705 

Treatment 705 

Chronic   Prostatitis   706 

Symntoms 706 

Diagnosis  706 

Etiology    707 

Treatment   707 

Abscess  of  the  Prostate    708 

A         Symptoms 708 

Etiology    7aS 

Treatment   708 

Prostatorrhea    70S 

Symptoms 708 

Etiology   709 

Treatment   709 

Atrophy  of  the  Prostate   709 

Hypertrophy  of  the  Prostate   7t)9 

Symptoms 709 

Diagnosis  710 

Etiology   and   Pathology    711 

Prognosis    712 

Treatment   712 

Operatiye   Treatment    713 

Vasectomy    713 

Castration  714 

Galvanocauterization  714 

A.    Bottini's   Operation    ....   714 




'Urinary  and  Genital  Systems,  Surgical 
Diseases  of,  Diseases  of  the  prostate, 
Hypertrophy  of  the  prostate,  Operative 
Treatment,  Galvanocauterization  (con- 

B.  Chetwood's  Operation   . .  714 

Cystostomy 714 

Prostatectomy   715 

Suprapubic    Prostatectomy    .  .  .   715 
Perineal    Prostatectomy        . .  .   715 

A.  Median    715 

B.  Extra-urethral    715 

Tuberculosis  of  the  Prostate  716 

Symptoms ' 716 

Diagnosis 716 

Etiology    716 

Treatment    716 

Tumors  of  the  Prostate   717 

Cysts    717 

Carcinoma    717 

Symptoms 717 

Diagnosis  717 

Treatment 717 

Sarcoma    718 

Treatment 718 

Diseases  of  the  Bladder  718 

Anomalies    718 

Treatment 718 

Exstrophy  of  the  Bladder  718 

Treatment 718 

Retention  of  Urine   719 

Definition    719 

Symptoms 719 

Etiology   719 

Complications  and   Sequelae   720 

Treatment 720 

Rupture  of  the  Bladder  722 

Symptoms  and  Diagnosis   722 

Treatment 723 

Cystocele 723 

Treatment 723 

Foreign   Bodies  in  the   Bladder   ....   723 

Symptoms 724 

Diagnosis    724 

Treatment 724 

Vesical   Calculus    724 

Symptoms 725 

Diagnosis    726 

Treatment 726 

Lithotomy 727 

Technique  of  Litholapaxy 727 

Technique  of  Lithotomy   728 

Perineal  Lithotomy,  Lateral   .  .   729 

Median    .......' 730 

Suprapubic  Lithotomy 730 

Tuberculosis  of  the  Bladder 731 

Symptoms 731 

Diagnosis   732 

Treatment 732 

Tumors  of  the  Bladder    733 

Varieties   733 

Symptoms     733 

Etiology  and  Pathology  733 

Diagnosis    734 

Prognosis    734 

Treatment 734 

Ulcer  of  the  Bladder   735 


LIrinary  and  Genital  Sysems,  Surgical 
Diseases  of,  Diseases  of  the  I'laddcr, 
Ulcer  of  the  Blader  (continued). 

Diagnosis    736 

Treatment    736 

Varicose  Veins  of  the  Bladder  736 

Treatment    736 

Fistula  of  the  Bladder  736 

Treatment    736 

Diseases  of  the  Seminal  Vesicles  736 

Anomalies 736 

Wounds    736 

Concretions   737 

Treatment    737 

Acute   Seminal    Vesiculitis    737 

Symptoms 737 

Diagnosis    737 

Treatment    737 

Chronic  Seminal  Vesiculitis  737 

Symptoms 737 

Diagnosis    737 

Treatment    737 

Tuberculosis  of  the  Seminal  Vesicles.  738 

Symptoms 738 

Diagnosis    738 

Treatment   738 

Tumors   738 

Diseases  of  the  Spermatic  Cord 738 

Anomalies   738 

Wounds 738 

Treatment   738 

Torsion   739 

Inflammation   739 

Treatment    739 

Hydrocele  of  the  Cord  739 

Treatment   739 

Solid  Tumors   739 

Urobilinuria 740 

Urticaria 740 

Definition    740 

Synonyms 740 

Symptoms 740 

Urticaria     Papulosa     (Lichen     Urti- 
catus)       740 

Urticaria  Bullosa  740 

Urticaria  Nodosa  (U.  Tuberosa )    ..   740 

Urticaria  Hemorrhagica    740 

Urticaria   Intermittens    740 

L^rticaria  Perstans   740 

Urticaria  Pigmentosa  741 

Diagnosis    741 

Etiology  741 

Pathology    741 

Prognosis    741 

Treatment 741 

Litems,  Diseases  of   742 

Malformations   742 

Rudimentary  Uterus  742 

Abscess  of  the  Uterus   742 

Embryological  Malformations 742 

One-horned  Uterus   742 

Two-horned   Uterus    742 

Double  Uterus 742 

Two-chambered  Uterus  742 

Fetal  Uterus   743 

Infantile    Uterus    743 

Puerile  Uterus   743 




Uterus,  Diseases  of,  Embryological  Mal- 
formations  (continued). 

Puerile  Cervix 743 

Symptoms  and  Diagnosis   743 

Treatment 743 

Stenosis  of  the  Cervix  744 

Symptoms 744 

Diagnosis     744 

Prognosis    744 

Treatment 744 

Laceration  of  the  Cervix   745 

Symptoms  and  Diagnosis   745 

Pathology   745 

Treatment 745 

Displacements  of  the  Uterus   746 

Etiology 746 

Anteflexion  and  Anteversion   748 

Symptoms 748 

Diagnosis  748 

Treatment   748 

Retroflexion  and  Retroversion  749 

Symptoms 749 

Diagnosis     749 

Treatment 749 

Prolapse  and  Procidentia   750 

Symptoms 750 

Diagnosis     750 

Treatment 750 

Inversion  of  the  Uterus  751 

Symptoms  and  Diagnosis   751 

Prognosis 752 

Treatment   752 

Tuberculosis  of  Uterus  and  Adnexa  . .  753 

Tuberculosis  of  the  Body  of  Uterus  .  753 

Symptoms  and  Diagnosis 753 

Treatment 753 

Tuberculosis  of  the  Cervix   753 

Symptoms    753 

Prognosis   753 

Treatment 753 

Tumors  of  the  Uterus 753 

Myoma  of  the  Uterus 753 

Symptoms    754 

Diagnosis    754 

Etiology 755 

Pathology  755 

Prognosis   755 

Treatment 755 

Carcinoma  of  the  Uterus  757 

Cervix  Uteri   757 

Squamous-cell  Carcinoma 757 

Cylindrical-cell   Carcinoma   ...  75S 

Symptoms  and  Diagnosis   758 

Prognosis    759 

Treatment   759 

Corpus   Uteri 760 

Symptoms    760 

Diagnosis    760 

Prognosis    760 

Treatment    761 

Dcciduoma   Malignum    761 

Treatment 761 

Sarcoma  of  the  Uterus   761 

Sarcoma  of  the  Cervix  761 

Symptoms  and  Diagnosis   761 

Sarcoma  of  the  Endometrium   ....  761 

Interstitial    Sarcoma    762 


Uterus,  Diseases  of.  Tumors  of  the 
Uterus,  Sarcoma  of  the  Uterus,  Inter- 
stitial Sarcoma   {continued). 

Symptoms    762 

Diagnosis    762 

Treatment     762 

Uva  Ursi   762 

Preparations  and  Doses    762 

Physiological    Action    762 

Therapeutic   Uses    762 

Uveal  Disorders.     See  Iris,  Ciliary  Body 

and  Choroid. 
Uvula.     See  Pharynx  and  Tonsils,  Dis- 
eases of. 

Vaccination.      See    Varioloid    and    Vac- 

Vagina   and   Vulva,   Diseases  of    763 

Acute  Vulvovaginitis   763 

Symptoms 763 

Etiology    763 

Treatment 764 

Chronic  Vulvitis 764 

Follicular  Vulvitis  764 

Glandular   Vulvitis    765 

Treatment 765 

Gonorrheal  Vulvovaginitis   765 

Diagnosis    765 

Etiology    766 

Treatment    766 

Infectious  Vaginitis    766 

Tuberculous  Vulvovaginitis   766 

Symptoms 766 

Treatment    767 

Diphtheritic  Vulvovaginitis 767 

Treatment    767 

Puerperal   Vulvovaginitis    768 

Treatment    768 

Eczematous    Vulvovaginitis    768 

Etiology    768 

Treatment   768 

Leucorrhea 769 

Symptoms    769 

Etiology    769 

Treatment    769 

Atrophy  of  the  Vagina  and  Vulva  . . .  770 
Hypertrophy  of  the  Vagina  and  Vulva  770 

Treatment    770 

Prolapse  of  the  Vagina  771 

Treatment   771 

Vaginismus    771 

Treatment    771 

Vaginal  Fistulae  772 

Treatment    772 

Mayo's  Technique   772 

Tumors  of  the  Vagina  and  Vulva  ....  773 

Benign    773 

Malignant   773 

Hcrnije    773 

Treatment    774 

Cysts  774 

Treatment    774 

Hematomata    774 

Treatment     775 

Miscellaneous   Growths    775 

Treatment    775 

Fungous  Growths    775 




Vagina  and  Vulva,  Diseases  of,  Tumors 
of  the  Vagina  and  Vulva.  Fungous 
Growths   (coiilinucd) . 

Treatment     775 

Foreign  Bodies  775 

Treatment    775 

Malignant  Growths  775 

Treatment     776 

Congenital  Absence 776 

Treatment 776 

Adhesions  777 

Acquired    Occlusion    777 

Varicocele 777 

Treatment 777 

Parasitic   Vulvitis    777 

Treatment 777 

Kraurosis  Vulva;   778 

Treatment 778 

Pruritus   Vulvae    778 

Treatment 778 

Vaginoperineal  Injuries.  See  Pregnancy 
and  Parturition,  Disorders  of. 

Vagotonia  and  Sympatheticotonia   780 

Symptoms 780 

Pathology   780 

Treatment 780 

Valerian    780 

Preparations  and  Doses  780 

Physiological   Action    780 

Therapeutics    781 

Valvular  Diseases  of  the  Heart.  See 
Endocardium  and  Heart, 
Diseases  of. 

Varicella   781 

Definition ■  • 781 

Symptoms 781 

Diagnosis    781 

Etiology    782 

Prognosis    782 

Treatment 782 

Varicocele.  See  Penis  and  Testicles, 
Diseases  and  Injuries  of. 

Variola    (Smallpo.x)     782 

Definition    782 

Symptoms    782 

Special   Forms    783 

Diagnosis  783 

Scarlatina  783 

Measles   783 

Typhoid  Fever   783 

Influenza 783 

Meningitis    783 

Cerebrospinal   Meningitis    783 

Etiology    783 

Prophylaxis   784 

Treatment 784 

Varioloid  and  Vaccination   785 

Varioloid 785 

Vaccination  785 

Technique  785 

Prevention  of  Infection  786 

Acupuncture  Method 786 

Symptoms    787 

Revaccination  787 

Efficacy  of  Vaccination   787 

Vascular  System,  Disorders  of   788 

Raynaud's  Disease 788 


Vascular  System,  Disorders  of,  Raynaud's 
Disease   (continued). 

Symptoms 788 

Etiology  and    Pathogenesis    788 

Treatment 789 

Erythromelalgia 790 

Symptoms 790 

Etiology  and  Pathology  790 

Treatment 790 

Acroparesthesia    791 

Symptoms 791 

Etiology  and  Pathology 791 

Pathogenesis    791 

Treatment 792 

Vasomotor  Ataxia  792 

Symptoms 792 

Diagnosis  793 

Treatment   793 

Traumatic  Neuroses   794 

Pathogenesis    794 

Symptomatology  795 

Vascular  System,  Surgical  Diseases  of  .  797 

Acute  Arteritis   797 

Symptoms  797 

Treatment    797 

Phlebitis    797 

Symptoms 797 

Etiology    797 

Prognosis   797 

Treatment    798 

Venous  Varix,  or  Varicose  Veins 798 

Symptoms 798 

Etiology    798 

Pathology 798 

Treatment    798 

Palliative  Measures  798 

Radical  Treatment    798 

Hemorrhage 799 

Symptoms 799 

Treatment     799 

Injuries  and  Wounds  of  Vessels  800 

A.  Arteries 800 

Contusion   800 

Rupture 800 

Punctured  Wounds  800 

Incised  Wounds  800 

B.  Veins    800 

Treatment   800 

Secondary  Hemorrhage 801 

Venous  Hemorrhage 801 

Thrombosis    801 

Varieties   801 

Symptoms     801 

Etiology  801 

Pathology    802 

Treatment    802 

Phlegmasia  Alba  Dolens  802 

Symptoms 802 

Diagnosis    803 

Etiology    803 

Pathology     803 

Complications 803 

Sequelc-e  803 

Prognosis    803 

Treatment   803 

Vasomotor  Neuroses.     See  Vascular  Sys- 
tem,  Disorders  of. 




Veins,     Disorders     of.       See     Vascular 


Venesection  and   Blood  Transfusion   ....  803 

Venesection    803 

Technique    803 

Indications    804 

Blood   Transfusion    804 

Technique 804 

Indications   805 

Venomous  Bites.     See  Index. 

Veratrum    805 

Preparations  and  Doses  805 

Physiological  Action   805 

Untoward  Effects  and  Poisoning 806 

Treatment    of    Poisoning    806 

Therapeutics    806 

Veronal 807 

Physiological  Action  807 

Poisoning  by  Veronal    807 

Treatment  of  Poisoning  by  Veronal  .  807 

Therapeutic  Uses  807 

Vitamines   808 

Warts.     See  Skin,  Surgical  Diseases  of... 

Water  (Hydrotherapy)    809 

Reaction    . 809 

Temperature  of  Baths   809 

Hydrotherapeutic  Measures   809 

The  Cold  Pack 809 

Evaporation   Bath    809 

The  Cold  Bath  810 

The  Half-bath  of  Priessnitz 810 

The  Spray  Bath  810 

The  Ablution  or  Wet-mit  Friction   .  810 

The  Drip  Sheet  or  Sheet  Bath  810 

Sponging   811 

The  Oil  Rub   811 

The  Scotch  Rub    811 

Salt  Rub  or  SaU  Glow   811 

Ice  Rub  or  Ice  Ironing  811 

Alcohol  Rub    811 

Douches 811 

Cold  Applications 812 

Hot  Applications    812 

Needle    Douche   or    Spray ;    Circular 

Douche  812 

Cold  Douche   812 

Spinal  Douche 812 

Alternating   Hot   and   Cold    Douches 

(Scotch    Douche)     812 

Head  Douches 812 

Rain  Douche  812 

Fan    Douche    812 

Filiform    Douche    812 

Perineal  Douche 812 

Aix    Douche    813 

Affusions    813 

Continuous   Baths    813 

The  Warm  Full  Bath  813 

Prolonged  Warm  Baths 813 

Warm  Baths  of  Short  Duration   ....  813 

The  Hot    Rath    813 

Special  Baths 813 

The  Brand  Bath  813 

The  Turkish  Bath  813 

The  Russian  Bath  (Diaphoretic)    ...  814 
Vapor  or  Sweating  Bath  814 


Water     (Hydrotherapy),    Special    Baths 
(cotitinucd) . 

Foot-bath    814 

Medicated  Baths 814 

Alkaline  Bath   814 

Pine-needle  Bath    814 

Sulphur  Bath    814 

Packs  814 

Cold  Wet  Pack  814 

Hot  Wet  Pack 814 

Dry  Hot  Pack 814 

Compresses 814 

Cold  Compress   814 

Ice  Compresses  815 

Hot  Compresses   (Fomentations)    ...   815 
Weil's  Disease.     See  Liver  and  Gall-blad- 
der :  Acute  Infectious  Jaun- 
Wen.     See  Skin,  Surgical  Diseases  of. 
Whooping-ceugh.     See  Pertussis. 
Wintergreen.     See  Gaultheria. 
Witchhazel.     See   Hamamelis. 
Worms.     See  Parasites,  Diseases  Due  to. 

Wounds,  Septic  and  Sepsis  815 

Prophylaxis 815 

Commonly  Used  Antiseptics  815 

Sodium  Hypochlorite  or  Dakin-Car- 

rel  Solution   .- . .  816 

Daufresne's  Technique  816 

Wound  Excision  and  Primary  Suture  .  819 

Delayed  Primary  Suture 820 

Secondary   Suture    820 

General  Infections;  Sepsis   822 

Toxemia  or  Sapremia   822 

Septicemia  823 

Pyemia  824 

Etiology  and    Pathology    825 

Toxemia  or  Sapremia 825 

Septicemia,    Sepsis,    Septic    Infec- 
tion    826 

Pyemia 826 

Prognosis    826 

Treatment    827 

Local   Measures    827 

Dichloramine-T   828 

Flavine    830 

Brilliant  Green   830 

Bismuth  Iodoform  Paste 831 

Serums   and   Vaccines    833 

Babcock's  Method    833 

General  Measures 834 

Puerperal   Sepsis    835 

Symptoms    835 

Etiology    836 

Diagnosis    836 

Treatment   , 837 

Wounds,    Venomous.      See    Wounds   and 

Xanthoma    837 

Etiology    837 

Pathology   837 

Prognosis    838 

Treatment     838 

Xanthoma   Diabeticorum    838 

Pathology   838 

Prognosis   838 




Xanthoma    Diabeticorum    (continued). 

Treatment 838 

X-ravs  and  Radium   838 

X-rays  838 

Physiological  Action   838 

Untoward   Effects    839 

Therapeutic    Dosage     839 

Apparatus 839 

Estimation  of   Dosage    840 

Filters    841 

Therapeutic   Uses    841 

Diseases   which    Benefit   by    X-ray 

Stimulation 841 

Diseases  which   Benefit  by  Reduc- 
tion of  Tissue  Activity .841 

Diseases  which  Benefit  by  Destruc- 
tion of  Cells 841 

Radium 841 

Physiological    Action    841 

Therapeutic  Uses  842 

Yaws 843 

Synonyms  843 

Symptomatologv'    843 

The  Primary  or  Prodromal  Stage  ..  843 
The    Secondary    or     Granulomatous 

Stage   843 

The  Tertiary  Stage 843 

Infection  843 

Treatment   843 

Prophylaxis    843 

Yellow  Fever 843 

Symptomatology 844 


Yellow     Fever,     Symptomatology     (con- 

Fulminant  Cases   844 

Diagnosis    844 

Etiology    845 

Pathology  and  Pathogenesis    845 

Prognosis    845 

Prophylaxis   845 

Treatment 846 

Yohimbine    846 

Physiological    Action    846 

Untoward  Effects    846 

Therapeutic   Uses    846 

Zinc 847 

Preparations    and    Doses    847 

Irritant   (Soluble)    847 

Mild  (Insoluble)    847 

Physiological   Action    848 

Acute  Poisoning  by  Zinc  Salts   848 

Chronic  Poisoning 848 

Treatment  of  Acute  Poisoning 849 

Therapeutics    849 

Gastrointestinal  Disorders  849 

Respiratory  Disorders 849 

Nervous  Disorders    849 

Cutaneous  Disorders  850 

Catarrhal  Disorders   850 

Zingiber    850 

Preparations  and  Doses 850 

Physiological   Action    850 

Therapeutic  Uses  850 

Zona.    See  Herpes  Zoster. 




R  H  E  U  M  AT  I S  M.  — A  group  of 
affections,  sometimes  of  parasitic 
origin,  characterized  by  pain  and 
swelling  of  the  joints  and  muscles, 
and  which  may  be  acute  or  chronic. 
Under  this  term  may  be  grouped 
rheumatic  fever,  muscular  rheuma- 
tism, and  various  joint  manifestations 
dependent  upon  specific  infections 
such  as  gonorrhea,  scarlatina,  diph- 
tlieria,  etc.  Of  these  conditions,  the 
first  three  will  be  considered  seriatim 
in  this  article. 

Rheumatoid  arthritis  or,  according 
to  the  newer  classification  of  Gold- 
thwait,  (1)  chronic  atrophic  arthritis, 
and  (2)  chronic  hypertrophic  ar- 
thritis, have  been  considered  in  the 
article  on  Joints,  Surgical  Diseases 
OF,  in  vol.  vi. 


Rheumatic  fever  {acute  or  subacute 
rheumatism;  acute  articular  rheuma- 
tism), is  an  acute  and  subacute  infec- 
tious, febrile  disease,  characterized 
by  migratory,  multiple  artl^ritis,  sweat- 
ing, and  a  tendency  to  complicating 
inflammation  of  the  serous  membranes 
and  the  fibrous  tissues,  and  to  re- 

SYMPTOMS.  — Rheumatic  fever 
rarely     presents     marked     i)rodromal 

symptoms,  but  ordinarily  the  patient 
feels  weary  and  ill  for  from  one  to 
three  days.  Occasionally  fugitive 
pains,  sore  throat,  or  otitis  media 
precede  the  onset  of  the  disease. 
The  symptoms  of  the  acute  affection 
then  set  in  suddenly  with  chills,  which 
may  be  repeated  once  or  twice. 
Fever  appears  and  the  temperature 
rises  to  39°  or  40°  C.  (102.2°  or 
104°  F.)  ;  the  pulse  and  respiration 
are  accelerated,  the  tongue  furred; 
there  is  no  appetite,  but  thirst  is 
marked.  The  urine  is  scanty,  highly 
acid,  and  loaded  with  urates,  which 
give  it  a  dark-red  color  and  rapidly 
precipitate;  the  specific  gravity  of  the 
urine  is  high,  and  it  is  not  rare  to  ob- 
serve albuminuria  on  the  first  days  of 
the  disease.  Chemical  examination 
demonstrates  that  urea  as  well  as 
uric  acid  is  present  in  excessive 
quantity.  Hemoglobinuria,  pepto- 
nuria, urobilinuria,  and  cystinuria 
have  sometimes  been  observed. 

The  skin  is  covered  with  abundant 
perspiration  and  numerous  sudamina 
and  miliaria  often  appear  on  it.  The 
sweat  is  acid  and  of  a  peculiar  odor. 

Simultaneously  with  the  fever  the 
characteristic  signs  of  rheumatic  ar- 
thritis appear,  generally  in  the  articu- 



lations  of  the  foot  or  the  knee.  Fre- 
quently the  affection  begins  in  the 
ankle-joint,  and  after  some  days  the 
process  also  invades  the  knee,  the 
shoulder,  the  elbow-joint,  and  the 
wrist.  Occasionally  the  affection 
begins  in  the  joints  of  the  upper  ex- 
tremities. This,  when  it  is  the  case, 
ordinarily  occurs  in  persons  occupied 
in  hard  bodily  work.  The  larger 
joints  are  most  frequently  affected,' 
but  sometimes  the  small  joints  of  the 
fingers  and  toes  are  also  involved, 
especially  in  children.  A  single  joint 
rarely  continues  to  be  the  seat  of 
trouble  for  more  than  four  or  five 
days ;  the  affection  then  more  or  less 
suddenly  disappears,  commonly  dur- 
ing the  night,  and  one  or  more  other 
joints  are  attacked  in  turn.  At  one 
time  several  joints  may  be  involved 
to  a  varying  extent.  In  very  severe 
cases  almost  all  joints  may  be  af- 
fected simultaneously,  and  even  the 
articulations  of  the  jaws,  the  spine, 
and  the  ribs  may  be  painful  and  swol- 
len. Ordinarily  rheumatic  fever  at- 
tacks several  articulations,  but  mon- 
articular acute  rheumatism  has  also 
been  observed. 

According  to  statistics,  the  locali- 
zation of  the  disease  in  the  different 
joints  is  as  follows :  Ankle,  27.8  per 
cent. ;  knee,  17.9  per  cent. ;  wrist,  9.6 
per  cent. ;  shoulder,  6.2  per  cent. ;  hip, 
4.1  per  cent. ;  metatarsus,  Zj  per 
cent. ;  elbow,  2.2  per  cent. ;  metacar- 
pus, 1.2  per  cent.;  toes,  0.8  per  cent.; 
fingers,  0.8  per  cent. 

Analyzing  100  cases  of  so-called 
"rheumatism,"  the  author  found  that 
these  included  44  cases  of  arthritis 
and  3  of  muscular  rheumatism  to 
which  the  term  "rheumatism"  might 
be  fairly  applicable.  Thirty  of  the 
44  patients  gave  a  history  of  gonor- 
rhea.      Among     the     53     incorrectly 

diagnosed  cases  there  were  18  of 
syphilis,  with  a  positive  Wassermann, 
8  of  neuritis,  4  of  tuberculosis,  4  of 
flat  foot,  3  typical  cases  of  pellagra, 
2  each  of  neurasthenia,  arterioscle- 
rosis, sciatica,  and  tabes,  and  1  each 
of  chronic  nephritis,  chronic  gas- 
tritis, muscular  atrophy,  malaria,  per- 
nicious anemia,  and  myelitis.  Deade- 
rick    (South.  Med.  Jour.,   Dec,   1918). 

The  affected  joints  are  very  painful 
and  swollen ;  the  overlying  skin  is 
red,  hot,  tense,  and  edematous,  while 
pressure  upon  it  leaves  an  impression 
which  remains  visible  for  some  time. 
Swelling  of  the  joint  is  caused  prin- 
cipally by  edema  of  the  skin  and 
ligaments,  but  occasionally  also  by 
an  effusion  in  the  articulation  itself. 
Upon  moving  the  diseased  articula- 
tion a  crackling  sound  is  sometimes 
heard ;  this  is  commonly  caused  by 
the  inflammatory  changes  in  the  ten- 
dons and  their  synovial  membranes. 
Moving  and  even  touching  the  af- 
fected joints  is  very  painful  to  the 
patient;  in  severe  cases  the  pain  may 
be  occasioned  by  very  small  commo- 
tions, e.g.,  by  walking  over  the  floor 
of  the  sick-room.  The  pain  seems  to 
be  localized  in  the  tendons  and  the 
muscles  in  the  proximity  of  the  joint. 
When  the  patient  is  induced  to  keep 
completely  quiet,  slight  movements 
of  the  diseased  joint  may  be  passively 
executed  without  causing  any  pain, 
whereas  the  most  trifling  active 
movement  is  accompanied  by  ex- 
cruciating pain. 

The  skin  over  the  affected  articu- 
lation shows  increased  sensibility  to 
changes  of  temperature,  but  a  dimin- 
ished sensibility  to  faradic  irritation. 

Of  diagnostic  importance  in  the 
cases  in  which  they  are  present  are 
small  nodules — "rheumatic  nodules" 
— 1  to  4  mm,  in  diameter,  generally 


not  tender,  appearing-  in  areas  where 
bones  underlie  the  skin  or  in  the 
synovial  sheaths  of  tendons.  These 
occur  especially  in  children.  They 
may  disappear  rapidly  or  only  after 
some  months.  Fibrosis  may  occur  in 

The  temperature  of  the  patient  is 
elevated  in  proportion  to  the  number 
of  the  affected  articulations ;  in  un- 
complicated cases  it  seldom  rises 
above  39°  to  40°  C.  (102.2°  to 
104°  F.),  but  it  may  also  oscillate  be- 
tween 38°  and  39°  C.  (100.4°  and 
102.2°  F.).  Acid  sweats  often  take 
place  consentaneously  with  remis- 
sions in  the  temperature. 

One  of  the  earliest  and  most  con- 
stant and  obscure  symptoms  of  rheu- 
matism in  children  is  a  persistent  low 
fever,  dropping-  daily  to  normal,  occa- 
sionally below,  and  seldom  going 
above  100°  F.  The  child  usually  feels 
well,  looks  well,  and  the  condition  is 
only  accidentally  discovered.  The 
first  suggestion  occurs  after  an  illness 
during  which  time  there  has  been  ele- 
vation of  temperature,  but  as  the 
other  symptoms  clear  up  the  tempera- 
ture chart  reveals  the  persistence  of 
a  small  amount  of  unaccountable 
fever.  A  complete  examination  may 
disclose  no  symptoms  other  than 
slight  acceleration  of  the  heart  on 
exertion.  One  naturally  thinks  of  tu- 
berculosis, but  gets  a  negative  von 
Pirquet.  Poynton  considers  this  tem- 
perature an  important  diagnostic 
symptom  of  very  early  rheumatic  in- 
fection. J.  A.  Colliver  (Arch,  of 
Pediat,  Jan.,  1914). 

The  pulse  is  soft  and  usually  above 
100  in  rate.  Evidences  of  toxemia, 
such  as  coated  tongue,  constipation, 
and  splenic  enlargement  are  likely  to 
be  observed. 

The  duration  of  rheumatic  fever 
varies  from  some  days  to  several 
weeks  or  even  months ;  it  is  liable  to 

remissions  and  exacerbations,  and, 
especially  when  the  patient  leaves  the 
bed  or  the  sick-room  too  soon,  exacer- 
bations are  frequently  observed.  In 
some  cases,  the  fever  having-  de- 
clined, one  or  more  joints  remain 
swollen  and  painful  for  a  long  time. 
A  critical  decline  of  the  temperature 
is  rarely  observed. 

When  the  joint  swellings  subside 
the  cuticle  commonly  cracks  and 
peels  off  in  small  scales.  As  many 
red  blood-corpuscles  become  de- 
stroyed during  a  severe  attack  of 
rheumatic  fever,  the  patients  get 
pale  and  weary.  The  anemia  often 
continues  for  a  long-  period  after  re- 
covery from  the  disease  itself.  Leu- 
cocytosis,  up  to  a  maximum  of  20,000, 
has  been  observed  to  develop  early  in 
the  rheumatic  attack  and  to  decline 
with  equal  rapidity  during-  con- 

Some  authors  refer  to  a  larval  form 
of  rheumatic  fever,  characterized  by 
neuralgia  of,  e.g.,  the  trifacial  or  the 
sciatic  nerve,  accompanied  by  high 
fever,  but  without  involvement  of  the 
joints,  and  yielding  rapidly  to  the  use 
of  salicylates.  During  an  epidemic  of 
rheumatic  fever  endocarditis  or  peri- 
carditis with  high  fever  is  sometimes 
observed  in  patients  who  do  not  suf- 
fer from  any  involvement  of  the  ar- 
ticulations ;  such  cases  have  been 
denominated  polyarthritis  rhcumatica 
sine  arthritide. 

COMPLICATIONS.— These     are 

very  frequent  and  aft'ect  especially 
the  heart  and  the  nervous  system. 
Verrucose  and  even  ulcerative  endo- 
carditis is  observed  in  a  large  pro- 
portion of  cases,  especially  when  the 
fever  is  high  and  many  joints  are 
affected.  Pericarditis  is  not  quite  so 
frequently     observed.        Endocarditis 


has  been  estimated  to  occur  in  about 
20  per  cent,  of  all  cases,  and  pericar- 
ditis in  about  14  per  cent. ;  but  these 
proportions  vary,  the  epidemics  of 
rheumatic  fever  differing  very  much 
in  regard  to  severity  and  frequency 
of  complications.  Bosanquet,  in  a 
series  of  450  cases,  noted  endocar- 
ditis in  28  per  cent,  of  the  males  and 
33  per  cent,  of  the  females,  and  some 
observers  place  the  incidence  of  endo- 
carditis at  50  to  75  per  cent.  The 
likelihood  of  endocarditis  is  increased 
by  youth  of  the  patient  and  where 
preceding  attacks  have  occurred. 
The  mitral  valve  is  that  oftenest  in- 
volved. Pericarditis  is  observed  in 
the  majority  of  the  cases  ending 
fatally,  and  may  be  fibrinous,  sero- 
fibrinous, or  purulent. 

In  almost  all  cases  some  dilatation 
of  the  right  heart  due  to  toxic  myo- 
carditis, is  found.  A  murmur  heard 
over  the  heart  is  thus  often  not  due 
to  endocarditis,  but  to  cardiac  dilata- 
tion (or  to  anemia).  In  consequence 
of  endocarditis,  the  myocardium  may 
also  be  affected  either  by  simple  ex- 
tension through  contiguity  or  by  em- 
boli. A  condition  of  complete  car- 
diac inflammation  or  pancarditis  may 
occur.  Slight  weakening  of  the  myo- 
cardium may  be  manifested  by  gen- 
eral weakness,  attacks  of  pain,  or 
tachycardia.  The  symptoms  of  endo- 
carditis and  pericarditis  are  discussed 
elsewhere  in  this  work. 

D.  B.  Lees  describes  the  cardiac 
complications  of  rheumatism  in  child- 
hood as  follows :  The  first  indication 
of  endocarditis  is  a  systolic  murmur 
at  the  apex.  Often  the  second  sound 
becomes  doubled,  after  a  time,  the 
doubling  being  heard  only  in  the 
apex  region,  different  from  the  dupli- 
cated pulmonary  sound  of  advanced 

mitral  stenosis.  The  first  element  of 
the  second  sound  always  remains 
sharp  and  short  as  long  as  it  is 
audible  at  all.  The  second  element 
may  be  substituted  by  a  short  blow- 
ing, early  diastolic  or  middiastolic 
murmur.  At  a  later  stage  there  may 
be  at  the  apex  a  presystolic  murmur, 
followed  by  a  longer  and  louder  sys- 
tolic. This  presystolic  murmur  is 
blowing  in  character,  usually  short, 
common  in  children  after  a  rheumatic 
attack,  and  generally  accompanied 
by  evidences  of  great  dilatation  of  the 
heart.  Care  should  be  taken  not  to 
consider  a  soft,  double  sound  at  the 
base  an  evidence  of  commencing 
aortic  disease.  It  is  often  the  first 
indication  of  pericarditis. 

While  in  adults  the  disease  spends 
itself  chiefly  upon  the  joints,  in  the 
child  it  has  a  much  greater  tendency 
to  attack  the  heart;  the  joint  involve- 
ment in  the  latter  is  often  so  slight 
as  to  be  overlooked,  yet  the  cardiac 
•  involvement  may  be  severe.  Ton- 
sillitis is  in  the  child  a  frequent  pre- 
cursor of  rheumatism,  while  chorea 
is  at  times  a  sequel.  Cardiac  involve- 
ment might  come  w^ithin  24  hours  of 
the  beginning  of  the  rheumatic  at- 
tack and  its  discovery  depends  upon 
a  careful  routine  study  of  the  heart. 
The  mitral  lesions  thus  caused  are 
capable  of  complete  recovery,  though 
the  aortic  lesions  practically  never 
recover.  D.  Riesman  (Trans.  Phila. 
Co.  Med.  Soc;  Med.  Rec,  Apr.  16, 

Rheumatism  in  the  child  can  be 
discovered  at  the  age  of  5  years,  pos- 
sibly earlier.  Earlier  signs  of  the 
disease  are  an  incessant  restlessness, 
a  constantly  accelerated  pulse  rate, 
often  reaching  100  or  over,  and  very 
frequently  a  constant  fever  of  a  little 
over  99°  F.  (37.2°  C.)  to  a  little  more 
than  100°  F.  (37.8°  C).  That  such 
a  rise  of  temperature  and  of  pulse 
rate   are   not   due  to   nervous   excite- 


merit  is  proved  by  their  being  found 
for  years  in  the  same  child  and 
always  at  about  the  same  level  for 
any  one  child.  This  observation  is 
based  upon  over  SOOO  temperature 
r-ecords.  M.  H.  Williams  (Lancet, 
June    19,   1915). 

Very  dangerous  and  rather  fre- 
quent are  the  complications  involving- 
the  brain.  In  some  cases  the  symp- 
toms are  only  caused  by  hyperpy- 
rexia; when  the  temperature  rises  to 
41°  or  42°  C.  (105.8°  or  107.6°  F.) 
or  even  to  43°  C.  (109.4°  F.),  when 
sweating  is  very  profuse,  and  signs 
of  endocarditis  develop,  there  is  im- 
minent danger  of  cerebral  rheuma- 
tism. When  symptoms  of  meningitis 
occur,  they  are  not  necessarily  due 
to  actual  inflammation  of  the  menin- 
ges, but  may  be  caused  by  hemor- 
rhage, edema,  or  hyperemia.  A 
uremic  condition  of  the  blood  may 
also  lead  to  cerebral  symptoms. 

Cerebral  rheumatism  may  manifest 
itself  in  different  ways : — 

1.  When  it  is  foudroyant  the  pa- 
tient is  suddenly  seized  with  agita- 
tion ;  although  previously  unable  to 
make  a  movement  without  extreme 
pain,  he  now  leaves  the  bed  and 
walks  about,  speaks  and  cries,  and 
suddenly  collapses  and  dies.  The 
temperature  ranges  from  42°  to  43° 
C.  (107.6°  to  109.4°  F.)  and  often 
even  exceeds  these  levels  after  death. 

2.  An  acute  form  of  cerebral  rheu- 
matism is  more  often  observed. 
There  is  likewise  high  fever;  the 
delirium  commences  more  quietly, 
but  after  a  little  time  the  patient  be- 
comes agitated,  and  may  have  epi- 
leptiform seizures,  these  symptoms 
being  followed  by  profound  coma  and 
commonly  by  death.  In  a  few  in- 
stances cerebral  symptoms  are  ob- 
served   with    a    temperature,  not   ex- 

ceeding 39°  C.  (102.2°  F.).  The 
pulse  rate  is  proportionate  to  the 
fever  and  may  reach  120  to  140  per 
minute.  The  duration  of  this  form  of 
cerebral  rheumatism  is  commonly  two 
or  three  days,  but  may  be  ten  to 
twelve  days.     Recovery  is  rare. 

3.  The  subacute  or  chronic  form  of 
cerebral  rheumatism  appears  in  the 
later  stages  of  rheumatic  fever  and 
is  ordinarily  of  a  melancholic  and 
stuporous  character.  The  patients 
refuse  to  speak,  even  to  eat,  and  are 
often  harassed  with  hallucinations. 
They  may  remain  in  this  condition 
for  months,  but  the  affection  ordi- 
narily ends  in  recovery. 

Spinal  complications  have  been 
described,  but  their  existence  hasi  not 
been  proved  beyond  doubt.  The 
peripheral  nerves  may  also  be  affected 
during  rheumatic  fever,  but  far 
oftener  such  disturbances  occur  some 
time  later,  as  a  sequel.  Chorea,  mul- 
tiple neuritis,  neuralgia,  and  sciatica 
have  been  witnessed  by  trustworthy 
observers.  During  an  epidemic 
Steiner  saw  35  cases  with  disease  of 
the  peripheral  nerves — often  in  the 
distribution  of  a  single  nerve — char- 
acterized by  pain  and  tenderness. 
In  8  of  these,  swelling  of  the  joints 
was  not  important,  though  there  was 
tenderness.  Steiner  claims  that  the 
nerve  pains  were  due  to  a  perineuritis.^ 

Complications  involving  the  re- 
spiratory organs  are  not  so  frequently 
observed.  Coryza,  tracheobronchitis, 
and  laryngitis  may  be  seen  during 
the  prodromal  stage.  During  the 
acute  stage  the  lungs  may  be  affected 
either  by  edema  or,  more  rarely,  by 
pneumonia,  particularly  of  the  migra- 
tory form.  Rather  frequently  the 
pleurae  are  involved.  A\'hcn  the  peri- 
cardium is  affected  tlic  disease  tends 


to  spread  to  the  left  pleura,  which  The  affection  of  the  joints  them- 
consequently  is  more  frequently  at-  selves  may  be  complicated  by  sup- 
tacked  than  the  right.  Rheumatic  purative  inflammation  leading-  to 
pleuritis  is  characterized  by  abun-  opening  of  the  articulation  and  to 
dant  fibrinous  membranes,  but  scanty  pyemia,  or  ending  in  ankylosis, 
exudation  of  serous  fluid ;  it  develops  In  occasional  instances  involve- 
very  rapidly  and  gives  rise  to  the  ment  of  the  eye  occurs  w^ith  rheu- 
ordinary  physical  signs  of  pleurisy  matic  fever,  being  manifest  in  con- 
in  a  very  marked  degree.  Its  dura-  junctival  congestion  or,  rarely,  iritis, 
tion  varies  from  three  to  eight  days.  Some  of  the  diseases  of  the  eye  as- 
Sometimes  the  right  pleura  is  ,at-  cribed  to  the  more  chronic  types  of 
tacked  while  left-sided  pleuritis  is  rheumatism  are:  iritis  and  episcleritis 
undergoing  resolution.  Peritonitis  is  — which  are  very  frequent — as  well 
a  rare  complication  which  may  be  as  deep  scleritis,  keratitis,  orbital  eel- 
associated  with  serous  pleuritis.  lulitis,      optic     neuritis,      choroiditis. 

Tonsillitis  is  a  frequent  manifesta-  ocular  palsy,   glaucoma,   and   opacity 
tion  of  the  prodromal  stage,  and  its  of  the  vitreous  (Woodruff), 
bacteria   are   now    considered   impor-  Chronic  nephritis   and  mental   dis- 
tant etiological  factors  in  the  develop-  ease  are  among  the  possible  ultimate 
ment  of  rheumatic  fever.  sequela  of  rheumatic  fever. 

Albuminuria    is    almost    constantly  In  children   cardiac   involvement   is 

observed;  acute  nephritis  and  hema-  relatively  more  frequent  and   impor- 

turia   may   occur.     Anuria   is   a   rare  tant    than    in    adults    and    generally 

complication ;  it  may  be  caused  either  leads  to  a  fatal  termination,  promptly 

by  acute  nephritis  or  by  emboli  from  or  ultimately.    The  onset  is  generally 

an  endocarditis.  abrupt,   sometimes  with  convulsions. 

Cystitis,    hydrocele,    and    orchitis  High  fever  sets  in  and  anemia  rapidly 

have    been    mentioned    by    some    as  becomes  pronounced.     Joint  involve- 

occasional  complications.  ment  is  comparatively  a  less  striking 

The    cutaneous    complications    in-  feature  than  in  adults, 

elude     roseola,     urticaria,     erythema  DIAGNOSIS. — The     diagnosis     is 

multiforme,  herpes  facialis,  and,  more  usually  easy,  the  migratory  arthritis, 

rarely,  erysipelas,  gangrene,  purpura  fever,    acid    sweats,    and    infrequency 

with  ecchymotic  spots  or  bullse  con-  of  involvement  of  joints  such  as  the 

taining  a  serous,  bloody,  or  purulent  sternoclavicular,    temporomandibular, 

fluid.        Hemorrhagic      complications  intervertebral,    and    sacroiliac    being 

have  also  been  observed  in  the  form  characteristic.     The  thyroid   is   often 

of  melena  and  metrorrhagia.  found  enlarged  in  children,  owing  ac- 

The   muscles    in   the   proximity    of  cording  to  Sajous,  to  a  defensive  re- 

the  aff'ected  joints  are  always  painful  action  of  this  organ. 

and    swollen ;    this    may    also   be   ob-  Enlargement  of  the  thyroid  gland 

served   in   the  case  of  muscles  more  claimed   to  be   a   diagnostic   sign   of 

distant   from  the  diseased  joints.      In  rheumatism    in    children       In     some 

cases  it  preceded   all   other   manifest 

rare  instances  true  inflammation  atid 
abscesses  have  been  observed  in  the 
muscles.  the  -rheumatic    chain,    and    in    others 

signs  of  the  disease;  in  others  it  ap- 
abscesses  have  been  observed  in  the  peared  as  the  fourth  or  fifth  link  in 


still    it   was    found   to    persist   along         The  arthritides  accompanying  such 

with  established  chronic  endocarditis  conditions  as  scarlet  fever  and  cere- 

after    all    other    rheumatic    manifesta-  ^rospinal     meningitis     are     commonly 
tions  had  disappeared.    J.  R.  Clemens         .      '       •       ^  vi 

(Arch,  of  Pediat.,  May,  1910).  ^^    septic    type,    With    accompanymg 

In  children  the  cardiac  phenomena  constitutional  symptoms  of  sepsis. 
are  paramount,  but  compression  of  Acutc  Osteomyelitis. — This  condi- 
the  left  lung  by  the  pericardial  exu-  ^j^j^  jg  characterized  by  grave  con- 
date  may  cause  physical  signs  of  g^itutional  evidences  of  sepsis,  and 
pneumonia  in  this  lung  to  occur.  The  .  .  .  .  r  ^.^ 
^  ,  .  •  ,•  1  ■  1  v.„  Jo  +v,«  by  especial  involvement  of  the  epi- 
most  characteristic   skin  lesion   is  the         .^         t"  .     ,       , 

so-called     rheumatic     nodule,     which  physis  and  shaft  of  one  of ^  the  bones 

histologically    resembles    the    mihary  articulating  at  the  afifected  joint.     The 

nodule    in    the   heart    muscle.      These  upper  extremity  of  the  tibia  and  the 

are    usually    few,    occasionally    enor-  j^^^^^.  ^^^  ^^  ^j^^  femur  are  the  locali- 

xnous     in     number      and     are     found  ^ies  most  frequently  affected. 

chiefly  about  the  elbows,  backs  of  the  ^  ,        ,•  ,   r 

wrists,  near  the  ankles,  and  over  the  Gout.—Gout  may  be  discerned  from 

buttocks.    D.  Riesman  (Trans.  Phila.  rheumatic  fever  by  the  fact  that  it  is 

Co.   Med.  Soc;    Med.  Rec,  Apr.  16,  never   accompanied    by    fever   of   the 

1921).  same  intensity  as  prevails  in  the  lat- 

Secondary     Infectious     Arthritis. —  ter  disease;  by  its  predilection  for  the 

Rheumatic  fever  may  be  confounded  great  toe ;  by  the  possible  presence  of 

with   the   secondary   multiple   inflam-  uratic  deposits  in  various  parts  of  the 

mations   of  joints   observed   in   acute  body,  and  by  its  special  occurrence  in 

infectious  diseases  such  as  scarlatina,  the  male  sex. 

cerebrospinal     meningitis,     puerperal         ETIOLOGY.  —  Rheumatic    fever 

infection,     rubeola,     diphtheria,     etc.,  tends     to     attack     especially     young 

and    also    with    the    pseudorheumatic  adults,     approximately     three-fourths 

affections  of  gonorrhea,  syphilis,  and  of   the   cases    occurring   between    the 

tuberculosis.     In  all  these  affections  asfes  of  15  and  35.    Infants  are  almost 

the  symptoms  of  the  major  disorder  safe,  but  no  age   is  entirely  exempt, 

are   present   and   facilitate   diagnosis.  The  disease  attains  its   greatest   fre- 

In  gonococcal   arthritis   there   is   a  quency  between  the  ages  of  20  and 

history    of    gonorrhea;    the    joint    in-  25  years. 

volvement  is  generally  monarticular,  Both    sexes    are   liable   to    the   dis- 

affecting     especially     the     knee     and  ease ;  among  adults,  men  are  perhaps 

wrist,  and  is  extremely  severe ;  con-  somewhat    more    frequently    affected 

stitutional  symptoms  are  less  marked,  than  women,  Init  that  is  probably  on 

and  the  joint  lesions  tend  to  persist  account  of  their  greater  exposure  to 

after  the  febrile  stage.  the  inclemency  of  the  weather.     Be- 

In  syphilitic  pseudorheumatism  the  tween  the  ages  of  10  and  15  the  dis- 

joint-symptoms  are  less  intense  than  ease   is   somewhat   more   common   in 

in    rheumatic    fever;   are    not   migra-  the   female   than   the   male   sex.      An 

tory ;  show  nocturnal  exacerbation  of  hereditary  predisposition  seems  to 
pain,    and    yield    rapidly    to    specific      exist     in     some     families.       Cheadle, 

treatment  (though  pain  is  relieved,  among  32  consecutive  cases,  found 
as  it  is  in  other  forms,  by  the  local  evidence  of  heredity  in  70  per  cent., 
application  of  methyl  salicylate).  and,   if   chorea   and   erythema   be   re- 



garded  as  forms  of  rheumatism,  in 
93  per  cent. 

Exposure  to  wet,  cold,  and  abrupt 
temperature  changes  predisposes  to 
rheumatic  fever,  which  is  therefore 
commonest  in  coachmen,  laborers, 
sailors,  and,  among  women,  in  washer- 
women and  domestics.  The  dis- 
ease is  frequent  only  in  temperate 
climates,  and  is  not  observed  in 
tropics  or  in  the  arctic  regions. 

The  exciting  cause  of  the  disease  is 
now  considered  to  be  unquestionably 
an  infection.  This  view  is  supported 
by  the  facts  that  it  occurs  epidem- 
ically, as  well  as  endemically,  and 
that  during  epidemics  the  cases  ac- 
cumulate in  some  houses,  whereas 
other  houses  are  quite  spared.  Me- 
teorological conditions  do  not  appear 
to  be  of  great  influence  on  the  epi- 
demics of  rheumatic  fever,  which 
have  been  observed  as  well  in  the 
sum.mer  as  in  winter,  during  dry  as 
well  as  wet  seasons.  The  epidemics 
vary  greatly  in  intensity  and  dura- 
tion, and  occur  at  irregular  intervals. 

It  is  still  doubtful  whether  rheu- 
matic fever  is  the  product  of  one 
specific  micro-organism  or  whether 
different  species  act  simultaneously 
or  independently  as  pathogenic  fac- 
tors. At  all  events,  the  clinical  and 
pathological  features  of  the  disease 
clearly  show  its  infectious  origin. 
That  streptococci  may  produce  it  has 
been  shown  by  a  number  of  ob- 
servers, who  have  not  only  recovered 
these  organisms  from  the  blood  and 
joints  of  patients,  but,  like  Schloss 
and  Foster,  reproduced  lesions  sug- 
gestive of  rheumatic  fever  in  lower 
animals.  The  organism  considered 
to  be  most  likely  the  actual  exciting 
factor,  or  at  least  that  operative  in 
the  largest  proportion  of  cases,  is  the 

Diplococcus  rheiintaticus  isolated  by 
Poynton  and  Paine,  who  found  it  not 
only  in  the  joints  and  blood,  but  in 
rheumatic  nodules  and  the  urine,  and 
with  it  produced  arthritis,  valvular 
lesions,  etc.,  in  rabbits.  This  organ- 
ism is  distinguishable  neither  mor- 
phologically, culturally,  nor  by  the 
opsonic  and  agglutinin  reactions 
(Tunnicliffe)  from  the  Streptococcus 
pyogenes,  but  only  by  the  production  of 
rheumatic  lesions  in  animals.  Poyn- 
ton and  Paine  consider  their  diplo- 
coccus  the  "only  bacterial  cause"  of 
acute  rheumatism.  Cole  believes  it 
imwarranted,  however,  to  recognize 
a  distinct  variety  of  streptococcus 
because  of  its  property  of  produc- 
ing arthritis  and  endocarditis,  as  he 
has  provoked  similar  lesions  in  ani- 
mals with  streptococci  from  various 
sources.  This  is  in  accord  with  the 
present  increasing  disinclination  of 
bacteriologists  to  believe  that  sharp 
lines  separate  similar  organisms  into 
distinct  varieties,  and  is  supported  by 
the  observations  of  Rosenow  (1914) 
that  the  affinity  of  cocci  freshly 
isolated  from  the  joints  in  rheumatism 
for  the  articulations,  endocardium, 
and  often  also  myocardium  and  vol- 
untarv  muscles,  which  tends  to  dis- 
appear  on  cultivation,  may  be  re- 
stored by  passage  through  animals, 
and  that  other  strains  of  streptococci 
under  certain  conditions  may  be 
made  to  acquire  the  properties  of 
the  strains  obtained  from  rheumatic 

Five  cases  have  been  published  to 
date  in  which  the  tuberculous  nature 
of  an  articular  rheumatism  has  been 
established  beyond  question.  The 
writer's  patient  was  a  girl  of  19  who 
had  had  glandular  tuberculosis  as  a 
child,  and  later  a  tuberculous  process 
in  the  lower  jaw  compelling  total  re- 


section.  Twelve  days  after  the  op- 
eration, moderate  fever  developed 
with  multiple  acute  swelling  of  joints. 
The  patient  died  in  a  few  months 
from  amyloids.  Autopsy  showed  tub- 
erculous nodules  in  the  synovial  mem- 
branes. Melchior  (Mitteil.  a.  d.  Grenzg-. 
d.  Med.  u.  Chir.,  xxii,  Nu.  3,  1911). 

Cultures  of  exudate  aspirated  from 
the  joints  in  acute  rheumatic  arthritis 
proved  uniformly  sterile.  Non-hemo- 
lytic  streptococci  were  recovered  in 
blood  cultures  from  less  than  10  per 
cent,  of  rheumatic  fever  patients. 
Similar  streptococci  were  recovered 
from  active  endocardial  lesions  in 
only  half  of  the  fatal  cases.  No  type 
of  streptococcus  is  constantly  asso- 
ciated with  acute  rheumatic  fever.  If 
the  streptococcus  actually  is  the  etio- 
logic  agent,  the  infection  occurs 
through  various  members  of  the 
viridans  group.  Swift  and  Kinsella 
(Arch,  of  Int.  Med.,  Mar.,  1917). 

Report  of  an  acute  case  in  a  girl  of 
17,  with  a  heart  injured  by  a  previous 
attack.  A  general  pericarditis  with 
copious  effusion  developed,  and  the 
fluid  withdrawn  by  paracentesis  showed 
numerous  minute  diplococci,  some  in 
the  fluid,  many  more  in  leukocytes. 
This  completely  supports  the  results 
of  experimentation  concerning  the 
micro-organism  of  rheumatic  fever. 
It  also  indicates  that  in  human  rheu- 
matic pericarditis  with  little  effusion 
but  with  great  thickening  of  pericar- 
dial tissues,  the  diplococci  are  shut 
in  the  necrotic  areas  but  imperfectly 
destroyed,  causing  the  intractable  re- 
lapsing cases  of  childhood.  Poynton 
(Brit.   Med.  Jour.,   Mar.  29,   1919). 

As  for  the  portals  of  entry  of  rheu- 
matic infection,  the  tonsils  demon- 
strajjly  play  an  important,  if  not  ex- 
clusive, role  in  this  direction.  Not 
only  are  the  tonsils  favorite  abodes 
of  virulent  streptococci,  and  attacks 
of  sore  throat  a  frequent  manifesta- 
tion of  rheumatism,  but  ori^anisms 
isolated  from  the  tonsils  of  rheumatic 
cases    have,     with     considerable    con- 

stancy, been  observed  to  induce  ar- 
thritis and  endocarditis  when  injected 
into  animals.  Permanent  cure  of  a 
rheumatic  tendency  has  frequently 
followed  removal  of  the  tonsils.  Ac- 
cording to  some,  the  gums,  the  nasal 
mucosa,  and  the  gastrointestinal  tract 
are  also  at  times  sources  of  infection. 

The  pleurisy  of  acute  rheumatism 
usually  yields  promptly  to  the  sali- 
cylates, but  if  it  is  left  untreated, 
serious  lesions  may  be  installed.  The 
rapid  invasion  of  the  pleura,  the  bi- 
lateral involvement,  the  association 
with  congestion  of  the  lungs  and  with 
pericarditis  without  effusion,  the  com- 
plete subsidence  without  sequels,  the 
fixity  and  long  duration  of  the  pleural 
effusion,  its  moderate  amount,  and 
the  usually  mild  character  of  the 
pains  in  the  chest  are  its  distinguish- 
ing features.  J.  Mollard  and  M. 
Favre  (Lyon  med.,  May,  1917). 

Peritonitis,  appendicitis,  bronchitis, 
and  pneumonia  are  sometimes  ascrib- 
able  to  rheumatic  infection. 

Micrococcus    rheumaticus    takes    the 
path  of  least  resistance.    This  may  be 
an  unhealthy  throat,  absorption  from 
which    frequently   gives    rise    to    gen- 
eral    rheumatic     infection,     including 
peritonitis    and    appendicitis,    directly 
through   the   vascular   system.      Or   it 
may    be    localized     in    the    bronchial 
tubes    and    give    rise    to    pneumonia, 
with     polyarthritis    and    endocarditis. 
An   unhealthy  condition   of  the  intes- 
tinal  wall  may   excite  to  activity  the 
rheumatic  agent.     Congestion   of  the 
pharynx,  palate,  and  fauces  in  a  child 
with   a   rheumatic  family  or  previous 
history,    or   with    a    rheumatic    facies, 
should  always  be  looked  on  seriously, 
and    met    with    local    applications    of 
salicylic    acid    preparations,    together 
with  sodium  bicarbonate,  sodium  sali- 
cylate, potassium  chlorate,  and  aperi- 
ents.    A   5    per   cent,   to   10  per   cent, 
solution   of  sodium  salicylate  applied 
to    the    tonsils,    palate,    and    pharynx 
protects  from  further  contamination; 
a   gargle   containing  20   to  40  grains 



(1.3  to  2.6  Gm.)  to  the  ounce  (30  c.c.) 
is  equally  efficacious.  Decayed  teeth 
should  be  filled  or  extracted,  and 
the  daily  use  of  the  tooth-brush  and 
antiseptic  powder  should  be  insisted 
on.  Inhalation  for  half  an  hour,  three 
times  a  day,  of  10  minims  (0.6  c.c.) 
of  a  solution  of  equal  parts  of  creo- 
sote and  phenol  is  the  best  method 
of  protecting  the  pulmonary  mucous 
membrane.  Sodium  salicylate,  com- 
bined with  sodium  bicarbonate  and 
rhubarb  powder,  is  by  far  the  best 
protective  treatment  in  cases  in  which 
there  is  any  indication  of  excess  of 
mucus  in  the  intestine.  J.  K.  Mac- 
kenzie (Brit.  Med.  Jour.,  June  1, 

A  woman  of  28  developed  subacute 
articular  rheumatism  and  endocarditis 
five  months  after  an  infected  abor- 
tion. No  benefit  was  procured  from 
a  month  or  more  of  the  ordinary 
measures,  including  the  salicylates, 
but  after  straightening  and  curetting 
the  uterus  the  temperature  dropped 
to  normal  and  rapid  recovery  fol- 
lowed, signs  of  mild  mitral  insuffi- 
ciency, however,  still  persisting.  Ar- 
ticular rheumatism  of  puerperal  origin 
generally  settles  down  in  one  joint 
after  a  time — the  shoulder  in  the 
writer's  case — and  stays  there.  Pierra 
(Revue  mens,  de  gynec,  d'obstet.,  et 
de  pediat.,  Mar.,  1914). 

PATHOLOGY.— In  all  cases  of 
rheumatic  fever  hyperemia  is  present 
in  the  joints ;  but  as  these  changes  are 
extremely  fugacious  it  is  ordinarily 
impossible  to  demonstrate  them  at 
autopsy.  In  more  advanced  cases  the 
synovia  is  augrnented  and  shows  mi- 
croscopically a  great  number  of  poly- 
nuclear  cells  containing  globules  of 
fat,  resembling  pus-cells.  In  some 
cases  the  cells  are  not  free,  but  are 
inclosed  in  a  network  of  fibrin,  ap- 
pearing to  the  naked  eye  as  small 
flakes.  True  pus  is  not  found  in  the 
joints  except  when  other  infections 
have    invaded    the   body    consentane- 

ously with  the  specific  infection  of 
rheumatic  fever.  The  synovial  mem- 
brane of  the  afifected  joints  is  then 
red  and  swollen,  with  its  capillaries 
engorged  with  blood;  the  cells  of  the 
synovial  membrane  tend  toward  mul- 
tiplication, containing  10  to  12  nuclei. 
The  cartilage  is  also  involved ;  its 
cells  multiply  and  form  oblong  cap- 
sules containing  many  secondary 
capsules.  The  macroscopic  result  of 
these  alterations  is  that  the  cartilage 
has  lost  its  natural  polish  and  that 
it  is  finely  striated.  These  patho- 
logical changes  are  common  to  all 
varieties  of  acute  arthritis  and  are 
not  characteristic  of  rheumatic  joint 
afifection.  Mainly  because  of  periar- 
ticular involvement,  some  of  the 
rheumatic  joints,  instead  of  promptly 
recovering  from  the  acute  process, 
mav  continue  in  a  condition  of  sub- 
acute  or  chronic  inflammation.  The 
tendons  and  even  the  periosteum  may 
be  attacked,  with  consequent  tender 
local  thickenings. 

The  rheumatic  alterations  of  the 
endocardium,  the  pericardium,  etc., 
revealed  by  autopsy  present  the  ordi- 
nary signs  of  an  acute  inflammation, 
but  nothing  which  is  characteristic 
of  rheumatic  fever  proper.  Acute 
dilatation  of  the  heart,  according  to 
Lees,  is  much  commoner,  even  in 
slight  attacks,  than  in  diphtheria  or 
influenza.  It  is,  however,  far  less 
dangerous.  Although  in  the  rheu- 
matic heart  there  is  evidence  of  fatty 
degeneration  of  the  muscle  fibers, 
with  interstitial  round-cell  foci,  the 
destruction  of  the  muscle  is  much 
less  pronounced  than  in  the  diph- 
therial heart. 

Children  are  prone  to  the  chronic 
or  subacute  manifestations  of  rheu- 
matism because  the  chief  site  of  the 



multiplication  of  the  organism  and 
the  manufacture  of  the  toxins  is  in 
focal  lesions  outside  the  blood- 
stream, while  in  adults  it  is  in  the 
blood  itself.  The  rheumatic  nodules 
afiford  the  typical  example  of  local 
response  to  rheumatic  infection. 
They  are  usually  associated  with 
grave  cardiac  mischief,  and  the  more 
numerous  and  the  larger  they  are  the 
more  serious  the  cardiac  involvement. 
While  present,  they  prove  the  per- 
sistence of  the  rheumatic  infection. 
The  lesions  found  in  the  heart  are 
similar  in  stru"cture  to  the  subcu- 
taneous nodules,  but  their  duration  is 
probably  less  prolonged.  In  the  meso- 
cardium  they  are  found  chiefly  in  the 
walls  of  the  left  ventricle,  especially 
near  the  mitral  and  aortic  valves.  In 
pericarditis  the  nodular  lesions  may 
be  confined  to  a  small  area  or  scat- 
tered all  over  the  pericardium.  In 
endocarditis  the  nodules  are  suben- 
dothelial,  and  are  situated  mostly  at 
the  upper  part  of  the  left  ventricle, 
especially  in  the  mitral  valve.  Gos- 
sage  (Pediatrics,  Apr.,  1912). 

Greater  attention  should  be  given 
to  the  various  types  of  acute  aneu- 
risms and  their  relations  to  acute 
rheumatic  fever.  The  almost  con- 
stant presence  of  some  inflammatory 
reaction  in  the  ascending  limb  of  the 
aorta  should  be  recognized  as  an  as- 
sociated conditi®n  in  this  disease. 
Klotz  (Jour,  of  Pathology  and  Bac- 
teriology, Oct.,  1913). 

During  the  course  of  rheumatic 
fever  the  blood  contains  much  more 
fibrin  than  normal. 

PROGNOSIS.— The  prognosis  is 
rather  good  as  regards  life,  as  very 
few  cases  end  fatally  (0.3  per  cent.). 
Usually  the  disease  terminates  in  two 
to  six  weeks  without  having  caused 
permanent  injury  to  the  joints  in- 
volved. Complications,  particularly 
those  involving  the  heart,  are,  how- 
ever, frequent  and  often  lead  to 
serious  consequences.  In  some  cases 
— subacute  rheumatic  fever — repeated 

exacerbations  in  the  joint  lesions  and 
temperature  occur  before  recovery 
finally  is  complete.  Hyperpyrexia 
and  suppurative  pericarditis  are  com- 
plications entailing  immediate  danger, 
while  endocarditis  acts  more  slowly. 
In  children  the  remote  prognosis  is 
always  grave,  death  taking  place  in 
youth  or  early  adult  life.  The  gravid 
state  also  renders  the  condition  more 
serious.  One  attack  of  rheumatic 
fever  predisposes  to  others,  and  the 
ultimate  prognosis  becomes  more 
somber  in  proportion  with  the  per- 
sistence of  recurrence. 

Twenty-three  per  cent,  of  acute 
articular  rlieumatism  patients  go 
through  one  or  more  attacks  without 
any  clinical  afifection  of  the  heart, 
irrespective  of  the  age  when  first  at- 
tacked; 22  per  cent,  develop  signs  of 
carditis  in  the  acute  stage,  these 
signs  disappearing  during  the  con- 
valescence; 18  to  20  per  cent,  of  the 
cases  which  develop  signs  of  endo- 
carditis, not  clearing  up  before  pa- 
tient leaves  the  hospital,  have  no 
permanent  valvular  lesion,  the  mur- 
murs being  due  to  myocarditis,  or  in- 
competence from  temporary  hyper- 
emia of  the  valves,  associated  with 
dilatation.  In  14.5  per  cent,  of  cases 
with  acute  rheumatic  endocarditis  of 
severe  type,  one  or  more  of  the  mur- 
murs disappear,  such  murmurs  being 
due  to  associated  dilatation.  Cases 
in  which  the  heart  is  going  to  recover 
completely  show  signs  of  such  re- 
covery within  twelve  months  of  the 
acute  attack,  thoug'.i  the  process  may 
not  be  completed  till  some  years 
later.  Kemp  (Quarterly  Jour,  of 
Med.,  Apr.,  1914). 

Analysis  of  350  fatal  cases  of 
rheumatism.  The  patients  comprised 
195  females,  155  males,  250  of  them 
under  the  age  of  12  years.  Rheuma- 
tism is  at  its  worst  from  the  sixth  to 
the  twelfth  year,  and  the  majority  of 
deaths  occur  before  the  twentieth 
year.     The   percentage   of   fatal   first 



attacks  in  childhood  was  nearly  23 
per  cent.  In  the  remaining  100  cases 
only  3  deaths  were  recorded  in  a 
first  attack.  Pericarditis  was  found 
in  215  of  the  250  cases  in  childhood. 
One  may  expect  to  detect  the  friction 
sound  in  at  least  80  per  cent,  of  the 
cases  of  recent  rheumatic  pericar- 
ditis; it  may  be  missed  because  the 
pericarditis  is  localized  posteriorly, 
very  limited  in  area,  or  evanescent. 
In  the  250  fatal  cases  in  childhood, 
the  mitral  valve  was   damaged  in  all 

^  but  3,  the  aortic  in  102,  the  tricuspid 
in  78,  the  pulmonary  in  6.  Among 
100  cases  in  children,  82  died  with 
evidence  of  acute  carditis.  Among 
100  older  cases,  only  9  died  of  acute 
carditis  of  the  childhood  type;  14  had 
recent  endocarditis  complicating  for- 
mer valvular  lesions;  in  55  the  valves 
were  scarred  by  old  disease,  and  22 
died  of  malignant  endocarditis.  The 
usual  time  for  malignant  endocarditis 
is  later  childhood,  adolescence,  and 
early  adult  life.  Death  from  myo- 
cardial failure  without  valvular  lesion 
occurred  in  only  3  of  the  350  cases. 
F.  J.  Poynton,  C.  D.  S.  Agassiz,  and 

■J.  Taylor  (Pract,  Oct.,  1914). 

TREATMENT.— In  the  treatineiit 
of  rheumatic  fever  it  is  of  importance 
that  the  patient  be  placed  in  a  large, 
well-ventilated  room.  He  should  be 
kept  in  bed,  even  where  the  affection 
is  mild.  A  flannel  nightgown  should 
be  worn,  and  the  patient  should  sleep 
between  blankets.  The  diet  should 
be  limited;  during  the  febrile  period 
liquid  food  should  alone  be  given, 
with  lemonade,  carbonated  waters, 
and  milk  as  beverages.  Regularity  of 
the  bowel  movements  should  be 

Many  authors  deem  it  preferable 
to  commence  the  treatment  by  in- 
stituting free  purgation. 

As  a  specific  remedy  against  the 
infection  itself,  salicylic  acid  and 
combinations  containing  this  drug 
have    nearly    supplanted    all    others. 

Salicylic  acid  may  either  be  given 
pure  or  in  combination  with  the 
alkalies  (sodium  or  strontium  salicy- 
late). Pure  salicylic  acid  is  best  tol- 
erated when  given  in  capsules  each 
containing  7j/2  to  15  grains  (0.5  to 
1  Gm.)  ;  this  dose  is  to  be  repeated 
fotir,  five,  or  even  six  times  per  day, 
until  the  pain  is  relieved  and  the  tem- 
perature falls.  When  symptoms  of 
intoxication,  viz.,  ringing  in  the  ears, 
nausea,  or  occasionally,  delirium  ap- 
pear the  use  of  the  remedy  must  be 
discontinued  for  twelve  to  eighteen 
hours,  or  the  dose  greatly  reduced. 
In  many  cases  the  pain  is  very 
rapidly  subdued  by  this  treatment 
and  patients  who,  in  the  morning 
were  not  able  to  move,  are  completely 
relieved  after  a  treatment  of  twelve 
hours.  In  other  cases  the  fever  sub- 
sides, but  the  pain  and  swelling  of 
one  or  more  joints  continue  for  some 
time.  Even  when  all  symptoms  have 
disappeared,  it  is  advisable  to  con- 
tinue the  use  of  salicylic  acid  for  some 
time,  btit  in  lesser  dose.  When  the 
use  of  salicylic  acid  is  discontinued 
too  soon,  recurrence  is  probable. 

Many  authors  prefer  the  use  of 
sodium  salicylate  which  is  sometimes 
given  in  solution,  1  to  1^  drams  (4 
to  6  Gm.)  or  even  2  drams  (8  Gm.) 
being  administered  per  diem.  It  has 
the  same  effect  on  the  disease  as  the 
pure  acid.  By  the  third  day  the  dose 
can  generally  be  reduced  to  15  grains 
(1  Gm.)  every  four  or  five  hours. 
Other  compounds  which  may  be 
used  are  ammonium  salicylate,  salicin, 
and  in  particular,  acetylsalicylic  acid 
(aspirin)  which,  being  nearly  taste- 
less, is  easily  taken  with  sugar  and 
water  on  a  spoon  or  in  milk,  and  is 
non-irritating  to  the  stomach,  pass- 
ing through  it  unaltered  into  the  in- 


testine    where  it  is  decomposed  and  passages     to     a    healthy     condition. 

absorbed  in  the  form  of  salicylic  acid.  1^"^^*^°^  ^"^  thorough  cleansing  of 

the  nasal  passages,  combined  with 
Inflammation  of  the  throat  empha-  antiseptic  treatment  of  the  nose  and 
sized  as  one  of  the  earliest  symptoms  pharynx,  should  be  a  routine  item  of 
of  rheumatism  and  a  gargle  of  20  antirheumatic  treatment;  and  the 
Gni.  (5  drams)  of  sodium  salicylate  operation  of  enucleation  should  be  per- 
in  1000  Gm.  (1  quart)  of  distilled  formed  without  delay  upon  all  rheu- 
water  recommended.  In  the  devel-  ^^^-^^  children  who  exhibit  chronic  en- 
oped  disease  one  should  endeavor  to  largement  of  the  tonsils  or  of  the 
administer  from  6  to  8  Gm.  (VA  to  2  tonsillar  lymphatic  glands.  W.  P.  S. 
drams)  in  twenty-four  hours  to  the  Branson  (Brit.  Med.  Jour.,  Nov.  23, 
adult;  in  children  1   Gm.   (IS  grains)  1912). 

per  diem  if   the   child   is  2   years   of  j      j  -i      • 

^             ,               ,  ^  r-        /on         •     ^   -^  The    writer    recommends    daily    in- 

age  or  less,  and  2  Gm.  (30  grains)  it  .                           i    *     o  r-        /-ic   ^.^ 

.*=      ^      -,    ',       ,         .         ,        1,  ,  jections   of  from  1   to  2  Gm.    (15   to 

4  or  5.     If  the  drug  is  not  well  borne  ^            ...            r     i  .        xv,^ 

,     ,             ,             ,1                  ^1  30  grams)  of  sodium  salicylate,     ine 

in   such    large    doses,    these   must   be  ^          '.                        r  n 

,  -    .          „  ^        /1T/    1          1/  solution   IS    made   as    iollows: — 
decreased  5,  4,  or  3  Gm.  (1%,  1,  or  % 

drams)    until    tolerance    is    produced.  Sodium  salicylate   5.0    parts. 

It   should    not   be   given    if   nephritis  Caffeine  citrate   0.25  part. 

with  the  presence  of  casts  in  the  urine  Distilled  ivater  25.0    parts. 

exists,  but  if  the  albuminuria  is  slight  q^  ^^-^^^  f^^^^^   5   ^^   10   c.c.    (1^   to 

and    there    are    no    casts    it    may    be  2^/^    drams)     are    given    daily.      The 

given  with  caution.  salicylate    must    be    chemically    pure 

When  the  myocardium  shows  signs  ^^^    ^^^    solution    kept    in    the    dark, 

of  being  afifected,  and  the  pulse  irreg-  j^  j^   ^^  special  value  where  medica- 

ular,     care    must    be     taken    not    to  ^.j^^^    ^^    mouth    is    not    well    borne, 

depress    the    heart    further.      If    the  p_     y_     Cgj-jiadas     (Semana     Medica, 

endocardium   or  pericardium  are  im-  -p^^    23^    1915). 

plicated,  the  salicylate  may  be  given,  t-.        '  •.                          a    ^\,       a     • 

^       .              ,         .  ,   ,               ,           ,  The  writer  recommends  the  admin- 

but  It  must  be  withdrawn  where  there  .                      -            v  '  1  ^^     t 

.      ,  ,.  .              ,       ,          .            r  istration  of  the  salicylates  by  rectum 

IS   delirium  and  other  signs   of  cere-  .                      1         u         *t        .           t 

T                              .  or  intravenously   where   the   stomach 

bral     excitement.       In    pregnancy    it  •          1    n-                   ^u 

....  is    rebellious    or    the    case    requires 

must  be  given  with  caution.     Aspirin  •  1       .•           -ri       •   4. 

.    ,           rr       ■          1        .1          1-     r  <.  rapid  action.     The  intravenous  injec- 

is  less  efficacious  than  the  salicylates,  '^                 r   m  *      on         •        /ha  ^-^ 

,     ,       ,  ,  ,         .         .      ,.-,,,  tions  are  of   10  to  20  grains    (0.6  to 

and  should  be  given  in  divided  doses  1  o  r-      \  •     oa                 <.        1   ..•            a 

-    5'        .,-          .r         •     X  1.3  Gm.)  in  20  per  cent,  solution  and 

up  to   1   to  3   Gm.   (15  to  45  grains)  .          /            Z        ^-          •      *        * 

^     ,                   ,.                                  .,  given  two  or  three  times  m  twenty- 

focn    '''rc:n°r"''^'7x/''^.''?r             ^  fo"^   hours    if    necessary.      Rectal    in- 

(0.50  to   1.50  Gm.-7/.  to  23  grains)  ^^^.^^^   ^^^   ^r.i.rr.A,   and   as   much 

also  has  its  uses.     If  these  remedies.  or             ,q         \              k        • 

r                    .          ,                       J           •  as    2    drams    (8    c.c.)    may    be    given, 

in    succession    do    not    produce    im-  •,,     1  c       •    •          r^          \      :   *4«^*,„... 

,  .      J  with    15    minims    (1    c.c.)    of   tincture 

provement,    they    can    be    combined  .                    ^  a    ■      ^      \        t,^„^c. 

^ .  .        ,     '                o    J-              1-     1  .^  of   opium,   repeated   in  twelve   hours, 

with    advantage:     Sodium    sahcylate,  n    r       \       ^         4.             1      ^   ,„ 

^^^  ^        ,.     ^  .     .           .  .      rtie  r-  The  alkaline  treatment  may  be  com- 

025  Gm.  (4  grains);  aspmn,  015  Gm.  ^.^^^  ^.^^^  ^^.^^  ^^^^  ^^^.^.^  .^  ^^_  ^^ 

i2}i    grains);    pyramidon.    0.15    Gm  ^O-  grain  (0.6  to  1.3  Gm.)  doses  may 

(2y4    grains).      In    cases    complicated  ^^  ^.^^^^  ^^^^^  ^^^  ^^^^^  ^j^^^  p^j^^ 

with  nephritis,  cupping  of  the  loins,  .^    ^^^    .^.^^^^    j^^^    diminished.      The 

milk  diet,  and  laxatives  are  indicated.  ^^^^    combination    internally    is    am- 

Lemoine    (Gaz.    des    pract.,    vol.    xix,  monium    salicylate,    5    to    10    grains 

1912).  (0.3   to  0.6   Gm.),   with   phenacetin,   1 

The    commonest    avenue    of    rheu-  to   2  grains    (0.06   to   0.13    Gni.),   and 

matic  infection  is  the  tonsil,  and  next  caffeine    citrate,    1    grain    (0.06    Gm.) 

to  it  the  nose.     The  first  essential  of  in  capsules,  every  two  hours.     Bever- 

rational    treatment   of    rheumatic   in-  ley    Robinson     (Med.    Rec,    Jan.    1, 

fection  is  restoration  of  the  upper  air  1916). 



The  first  essential  is  the  thorugh 
searching  out  and  removal  of  all  foci 
of  chronic  infection  and  the  prepara- 
tion of  an  autogenous  vaccine  from 
organisms  isolated  from  such  foci  or 
from  the  urine  if  foci  cannot  be 
definitely  located.  The  vaccines 
should  be  given  in  ascending  doses, 
every  week  or  ten  days,  adjusting  the 
dose  so  as  to  secure  a  slight  arthritic 
reaction.  After  improvement  has  ad- 
vanced, the  intervals  between  doses 
may  be  lengthened.  The  treatment 
should  be  continued  for  a  year  or 
more.  M.  J.  Rowlands  (Lancet,  Jan. 
15,    1916). 

Also  serviceable  where  the  simple 
salicylates  are  not  well  borne  is  salo- 
phen,  which  is  gradually  decomposed 
in  the  bowel  into  salicylic  acid  and 
acetylparamidophenol,  and  may  be 
given  in  doses  of  15  grains  (1  Gm.) 
every  three  hours,  preferably  in  con- 
junction with  sodium  bicarbonate,  10 
grains  (0.6  Gm.)  three  times  a  day 
(W.  H.  Flint).  This  drug  has  also 
been  recommended  for  use  late  in  the 
course  of  the  disease,  when  the  acute 
fever  has  been  mastered  with  salicylic 
acid.  Oil  of  wintergreen  may  also  be 
substituted  for  the  other  salicylates 
in  doses  of  20  minims  (1.25  c.c),  but 
is  not  unirritating  to  the  stomach. 

Salicin.  has  a  bitter  taste,  is  much 
less  nauseous  than  sodium  salicylate, 
and  can  be  conveniently  given  dis- 
solved in  hot  water.  It  only  yields  43 
per  cent,  of  its  weight  of  salicylic 
acid,  and  hence  the  amount  required 
is  at  least  double  that  of  sodium  sali- 
cylate—20  to  30  grains  (1.3  to  2  Gm.) 
every  hour  or  two  hours  until  1  ounce 
(30  Gm.)  has  been  given,  and  then 
smaller  doses  according  to  the  cir- 
cumstances. Acetylsalicylic  acid  is 
very  active  and  has  a  marked  anal- 
gesic effect.  It  cannot  be  prescribed 
with  alkalies,  which  decompose  it, 
and  hence  it  is  apt  to  bring  on  nausea 
and  vomiting  if  given  continuously. 
Methyl  salicylate  is  also  very  apt  to 

irritate  the  gastric  mucous  membrane, 
but  in  10-  to  20-  minim  (0.6  to  1.25 
c.c.)  doses  up  to  60  or  90  minims 
(3.75  to  5.6  c.c.)  per  day,  given  in 
emulsion,  or  on  sugar,  or  in  milk,  it 
acts  powerfully,  and  externally  ap- 
plied it  is  unrivalled  for  its  analgesic 
action.  Sodium  benzoate  has  the 
same  specific  effect  as  the  salicylate, 
but  acts  less  powerfully.  On  the 
other  hand,  it  is  practically  non- 
poisonous  and  has  no  disturbing  side- 
effects.  It  can  be  given  in  20-grain 
(1.3  Gm.)  doses  every  two  or  three 
hours  with  satisfactory  results  in 
cases  of  uncomplicated  rheumatic 
fever,  but  its  practical  usefulness  is 
merely  as  a  substitute  for  the  more 
powerful  salicylate,  when  the  latter 
cannot  be  tolerated.  Profuse  per- 
spirations and  skin  eruptions  are  in- 
conveniences which  frequently  follow 
salicylates.  They  are  also  often 
deemed  to  act  as  heart  depressants, 
but  this  is  not  borne  out  by  exact 
observations.  With  large  doses  (250 
to  400  grains— 17  to  27  Gm.— per 
day),  such  as  are  sometimes  given 
with  the  idea  of  thoroughly  destroy- 
ing the  infective  germ,  vomiting  fre- 
quently occurs,  and  it  is  possible  not 
only  to  seriously  depress  the  nervous 
system,  but  to  bring  on  a  dangerous 
condition  of  acidosis.  This  can  be 
prevented,  to  some  extent  at  least,  by 
giving  about  twice  the  amount  of 
sodium  bicarbonate  with  each  dose 
of  sodium  salicylate,  and  taking  care 
at  the  same  time  to  avoid  constipa- 
tion. But  in  an  ordinary  case  of 
moderate  severity  15  to  20  grains  (1 
to  1.3  Gm.)  of  sodium  salicylate  every 
three  or  four  hours  form  a  sufficient 
dose.  The  joint  pain  and  tempera- 
ture begin  at  once  to  be  favorably 
affected,  the  former  subsiding  in  from 
twelve  to  twenty-four  hours,  and  the 
latter  within  forty-eight  hours.  The 
pulse  and  respiration  fall  with  the 
temperature,  and  the  joint  effusion 
is  absorbed  in  two  or  three  days. 
The  course  of  events  usually  resem- 
bles a  crisis,  though  sometimes  a 
lysis.  If  the  temperature  does  not 
settle  satisfactorily  each  dose  may  be 



increased,  or  one  large  additional 
dose  of  40  to  60  grains  (2.6  to  3  Gm.) 
may  be  given  on  one  or  on  several 
daj's  in  succession.  Additional  ab- 
sorption of  salicylic  acid  may  be 
brought  about  by  applying  a  dressing 
of  methyl  salicylate  on  lint  to  the 
affected  joints.  Where  the  rheumatic 
infection  locates  itself  chiefly  in  the 
fibrous  tissues,  the  condition  generally 
in  time  yields  to  large  doses  of  sali- 
cylates, along  with  free  local  applica- 
tion of  methyl  salicylate.  When  these 
rheumatic  indurations  are  quite  re- 
cent, potassium  iodide  and  small  blis- 
ters exert  a  marked  deobstrucnt  effect. 
Massage  is  even  more  effectual. 
Stockman   (Pract.,  Jan.,   1912). 

The  writer  nearly  always  used  as- 
pirin and  sodium  salicylate  jointly, 
administering  as  mucli  as  10  or  15 
grains  (0.6  to  1  Gm.)  of  sodium  sali- 
cylate and  5  to  10  grains  (0.3  to  0.6 
Gm.)  of  aspirin  every  two  hours  al- 
ternately. W.  J.  Judy  (W.  Va.  Med. 
Jour.,  Aug.,   1912). 

Sodium  salicylate  with  sodium  bi- 
carbonate, 1  part  of  the  former  with 
2  parts  of  the  latter,  is  a  most  ef- 
fective antirheumatic,  if  the  dose  is 
gradually  increased  to  a  sufficient 
extent.  If,  when  vomiting  or  tinnitus 
occurs,  the  medicine  is  suspended 
for  a  few  hours,  the  unpleasant  symp- 
toms will  usually  pass  away,  and  the 
dose  can  later  be  raised  to  a  consid- 
erably larger  amount  without  causing 
their  recurrence.  In  a  rheumatic  at- 
tack it  is  often  desirable  to  increase 
the  amount  of  salicylate  to  150  or  200 
grains  (10  to  13  Gm.)  per  day,  with 
double  the  amount  of  sodium  bicar- 
bonate, given  in  10  doses.  It  is  im- 
portant to  prevent  constipation,  to 
keep  the  urine  slightly  alkaline  and 
to  stop  the  drug  when  vomiting  or 
other  symptoms  due  to  salicylate 
occur.  Lees  (Brit.  Med.  Jour.,  Oct. 
12,  1912). 

The  nodes  call  for  intensification  of 
the  treatment.  In  1  of  3  cases  in 
children  of  11  and  13,  salicylates  in- 
travenously and  by  the  mouth  were 
kept  up   for   7   montiis   with   slow  im- 

provement and  final  recovery,  even 
the  heart  functioning  normally  and 
the  child  increasing  22  pounds  in 
weight.  The  nodes,  though  extremely 
numerous,  persisted  for  3  months.  A 
girl  of  11  years  was  given  orally  in  4 
months  130  Gm.  (4%  ounces)  of  the 
salicylate  besides  intravenous  injec- 
tions up  to  a  total  of  9.5  Gm.  (2% 
drams).  Though  the  treatment  was 
ordered  discontinued,  the  parents 
continued  it  for  3  months  longer  (32 
injections  by  the  vein)  with  a  total  of 
16  Gm.  (4  drams),  perfect  recovery 
resulting.  Navarro  (Rev.  de  la  Asoc. 
Med.   Argentina,  Apr.-June,    1920). 

Nothing  certain  is  known  of  the 
manner  in  which  saHcylic  acid  and  its 
compounds  influence  the  rheumatic 
infection.  Possibly  salicylic  acid  has 
a  specific  action  on  the  micro-organ- 
isms;  it"  is  a  reliable,  but  not  an  in- 
fallible, remedy,  relieving  the  joint 
condition,  shortening  the  disease, 
diminishing  the  likelihood  of  relapse, 
and  probably  protecting  the  heart. 
Some  cases  are  rebellious  to  its 
action.  Some  patients  do  not  toler- 
ate it,  vomiting  being  induced.  It 
may  then  be  administered  by  inunc- 
tion or  enema.  For  inimction  a  20 
per  cent,  ointment  of  salicylic  acid 
or  of  methyl  salicylate  may  be  used. 
For  administration  by  enema  Erlan- 
ger  uses  the  following  formula: — 

R  Sodii  salicylatis.  3iss  to  ij  (6  to  8  Gm.). 
Tincturcc  opii  ..    Tri.lxxv   (5  c.c). 
Aqua f^iiiss    (100  c.c). — M. 

This  should  be  injected,  after  pre- 
liminary cleansing  of  the  bowels,  at 
body  temperature,  and  should  be  re- 
tained as  long  as  possible  in  the  in- 

Intrarectal  administration  of  sodium 
salicylate  recommended  in  refractory 
cases  of  acute  and  subacute  rheumatism. 
The  salicylate  enema  is  given  immedi- 
ately after  a  cleansing  soapsuds  en- 
ema,    and     is     administered     with     a 



Davidson  syringe  and  a  rectal  tube 
inserted  6  to  8  inches.  First  dose 
in  men  is  usually  8  to  10  Gm.  (2 
to  IVi  drams),  in  women  6  Gm. 
(1^2  drams),  incorporated  in  120  to 
180  c.c.  (4  to  6  ounces)  of  plain  or 
starrh  water,  with  1  to  1.5  <:.c.  (16  to 
24  minims)  of  opium  tincture.  The 
dose  may  be  repeated  within  12  hours, 
but  usually  a  daily  enema  suffices,  with 
doses  increasing  from  30  to  50  per 
cent,  daily  until  the  limit  of  tolerance 
is  reached.  L.  G.  Heyn  (Jour.  Amer. 
Med.  Assoc,  Sept.  19,  1914). 

Where  the  effects  of  salicylates  in 
acute  rheumatism  are  not  as  expected, 
the  so-called  "alkaline  treatment"  may- 
be instituted,  or,  the  two  forms  of 
treatment  may  be  combined — a  pro- 
cedure especially  useful  in  children. 
This  consists  in  the  administration  of 
20  or  30  grains  (1.25  or  2  Gm.)  of 
potassium  bicarbonate,  citrate,  or 
acetate,  or  sodium  bicarbonate  every 
two  or  three  hours  for  the  first  few 
days,  or  until  the  urine  is  alkaline. 
Luff  advises  combined  salicylic  and 
alkaline  medication  in  all  cases  of  rheu- 
matic fever.  He  gives  20  grains  (1.25 
Gm.)  of  sodium  salicylate  and  30 
grains  (2  Gm.)  of  potassium  bicarbo- 
nate every  two  hours  until  pain  is  re- 
lieved, then  every  four  hours  till  the 
temperature  has  fallen  to  normal.  Fif- 
teen grains  (1  Gm.)  of  the  salicylate 
and  20  grains  (1.25  Gm.)  of  the  bicar- 
bonate are  then  given  every  four  hours 
until  all  joint  symptoms  have  disap- 
peared, and  after  this  three  or  four 
times  a  day  for  a  fortnight  longer. 

Comparative  statistics  show  that  pa- 
tients do  not  recover  any  more  quickly 
under  salicylates  than  with  the  alk- 
aline treatment,  but  with  the  salicylate 
treatment  pain  is  sooner  relieved. 
Heart  complications  are  not  any  more 
common  when  treating  with  the  salicy- 
lates. J.  L.  Miller  (New  York  Med. 
Jour.,  July  4,  1914). 

Intravenous  and  subcutaneous  injec- 
tions of  salicylates  have  been  recom- 
mended by  several  observers,  both  to 
avoid  upsetting  the  stomach  and  for 
prompt,  powerful  effect.  Behr  lauds 
the  following  combination  for  intra- 
venous use,  originated  by  Mendel : — 

IJ  Sod'n  salicylatis  ...  3ij    (8  Gm.). 
Caffeince  sodiosal- 

icylatis  (N.  F.)  . .  5ss  (2  Gm.). 
Aqiice  stcril(c,  q.s.  ad  f5iss    (50  c.c). — S. 

Methyl  salicylate,  or  artificial  oil 
of  wintergreen,  is  recommended  for  ex- 
ternal use  in  rheumatic  fever.  It  is  a 
volatile  fluid  of  an  aromatic  odor.  The 
affected  joints  are  to  be  painted  with 
the  drug  and  enveloped  with  some  im- 
pervious material.  Experience  has 
shown  that  the  salicylic  acid  contained 
in  methyl  salicylate  is  absorbed  through 
the  skin.  It  is  also  chemically  demon- 
strable in  the  urine.  It  removes  the 
pain  and  reduces  the  temperature. 

In  acute  rheumatism  and  allied  con- 
ditions such  as  acute  rheumatic  sci- 
atica, the  result  of  thyroid  treatment 
may  be  striking.  Tompkins  (So.  Med. 
Jour.,  Dec,  1910). 

Hypodermic  injection  of  salicylates 
advocated,  for  the  purpose  of  secur- 
ing prompt  action  and  avoiding  di- 
gestive disturbances  and  toxic  symp- 
toms. In  acute  rheumatic  infection 
of  joints,  heart,  pericardium,  pleura, 
and  central  nervous  system  (chorea), 
inject  10  c.c.  (2^/2  drams)  of  20  per 
cent,  sterile  solution  of  fresh  sodium 
salicylate  per  100  pounds  of  body 
weight.  First  disinfect  a  spot  out- 
side of  the  median  line  of  the  thigh 
with  fresh  iodine  tincture.  Through 
this  inject  sterile  cocaine  solution  (^ 
grain — 0.008  Gm. — in  30  drops)  under 
the  skin,  and  after  waiting  fully  fif- 
teen minutes  inject  salicylate  solu- 
tion under  the  same  spot.  This  causes 
general  improvement  within  three 
hours.  Repeat  the  injection  every 
twelve  hours.  In  severe  cases,  with 
many  seats   of  involvement,   increase 



the  dose  to  15  c.c.  (^  ounce)  per  100 
pounds  weight.  In  chronic  cases,  in- 
ject every  twenty-four  hours  10  c.c. 
(2^  drams)  per  100  pounds  of  the 
following:  Salicylic  acid,  10  Gm.  (2^ 
drams);  sesame  oil,  80  Gm.  (2% 
ounces);  pure  alcohol,  5  Gm.  (75 
drams);  gum  camphor,  5  Gm.  (75 
grains).  This  is  to  be  sterilized 
before  adding  the  alcohol,  and  after- 
ward excluded  from  contact  with 
air,  to  avoid  evaporation  of  alcohol. 
The  effect  of  the  injection  in  chronic 
cases  is  obtained  more  rapidly  when 
multiple  localizations  of  the  rheu- 
matic process  are  present  than  when 
one  joint  is  affected.  In  the  former, 
pain  and  stiffness  usually  improve 
after  the  first  injection;  in  the  latter, 
after  the  third.  The  addition  of 
camphor  (from  5  to  20  per  cent.)  was 
found  beneficial  in  stimulating  the 
heart  when  the  pericardium  or  the 
endocardium  was  involved.  Seibert 
(Med.  Rec,  Mar.  11,  1911). 

Magnesium  sulphate,  administered 
by  intramuscular  injection,  by  mouth, 
and  applied  externally,  found  val- 
uable in  cases  of  acute  articular 
rheumatism.  Intramuscular  injec- 
tions of  4  c.c.  (1  dram)  of  a  sterilized 
25  per  cent,  solution  of  the  salt,  all 
aseptic  precautions  being  observed, 
brought  rapid  relief  from  pain,  re- 
duced stiffness  and  swelling,  and 
sometimes  considerably  lowered  tem- 
perature. No  pain  followed  the 
injections.  In  some  instances  purga- 
tion resulted.  Injections  were  re- 
peated on  succeeding  or  alternate 
days.  A  saturated  solution  was  ap- 
plied to  the  inflamed  joints  with 
benefit.  The  intramuscular  injections 
are  recommended  for  cases  in  which 
salicylates  fail  to  give  results.  A.  B. 
Jackson  (N.  Y.  Med.  Jour.,  June  24, 

In  many  cases  where  the  salicylates 
failed  in  their  action,  or  were  not 
well  borne,  coUargol  in  the  form  of 
an  intravenous  injection,  2  c.c.  (32 
minims)  of  a  5  per  cent,  solution,  or 
an  enema  of  50  c.c.  (1%  ounces)  of 
a  5  per  cent,  solution,  gave  excellent 
results.    In  giving  the  intravenous  in- 

jection the  heart  must  be  normal,  as 
there  is  a  sudden  rise  of  temperature 
to  40°  C.  (104°  F.);  the  injection  per 
rectum  is  not  followed  by  this  rise  in 
temperature,  and  the  results  are  about 
the  same.  Junghaus  (Deut.  med. 
Woch.,  Nov.  1,  1912). 

Case  of  rheumatic  fever  in  which, 
although  sodium  salicylate  appeared 
at  first  to  be  giving  excellent  results, 
the  pain,  joint  swelling,  and  fever 
later  returned,  the  heart  rate  in- 
creased, and  the  first  sound  became 
muffled.  Ten  days'  energetic  treat- 
ment with  the  salicylate  proving  com- 
pletely ineffectual,  8  Gm.  (2  drams) 
of  antipyrin  were  administered  in 
two  days,  and  the  salicylate  in  daily 
doses  of  5  Gm.  (75  grains)  resumed 
immediately  after.  The  fever  was 
thus  rapidly  overcome  and  convales- 
cence entered  upon.  The  return  to 
a  massive  dose  of  the  salicylate  after 
the  two  days'  intermission  seemed  the 
essential  factor  in  the  benefit  ob- 
tained. Interrupted  administration  of 
salicylates  has  already  been  recom- 
mended for  obstinate  cases,  and  anti- 
pyrin seems  especially  suitable  for 
use  during  the  intervals.  Roch  (Rev. 
med.  de  la  Suisse  romande,  Feb., 

The  writer's  experience  with  the 
intravenous  administration  of  sodium 
salicylate  comprises  12  cases  of  artic- 
ular rheumatism  of  various  degrees 
of  severity,  in  which  about  130  injec- 
tions were  used.  The  two  most  im- 
portant points  to  be  observed  in  the 
giving  of  the  injections  were  found 
to  be:  (1)  to  use  only  a  very  fine, 
sharp  needle,  so  that  the  trauma  to 
the  vein  wall  may  be  as  slight  as  pos- 
sible; and  (2)  to  have  the  solution 
fresh  and  made  with  chemically  pure, 
crystalline  sodium  salicylate.  The 
stock  solution  was  made  by  dissolving 
10  Gm.  (214  drams)  of  C.  P.  crystal- 
line sodium  salicylate  in  50  c.c.  (1% 
ounces)  of  distilled  water,  freshly 
sterilized  by  boiling.  The  drug  was 
weighed  and  handled  as  aseptically  as 
possible  and  the  solution,  after  being 
made,  not  subjected  to  further  sterili- 
zation.    The  solution  should  be  per- 




fectly  colorless  and,  if  protected  from 
the  light,  was  found  to  keep  for 
several  days.  L.  A.  Conner  (Med. 
Rec,  Feb.  21,  1914). 

Attention  to  the  joints  in  rheu- 
matic fever  is  of  great  importance. 
They  should  be  placed  at  complete 
rest  by  means  of  splints,  and  may 
also  with  advantage  be  wrapped  in 
cotton  or  in  cloths  wet  with  a  satu- 
rated solution  of  magnesium  sul- 
phate or  with  lead  water  and  lauda- 
num. Methyl  salicylate,  as  already 
mentioned,      may      also      be      applied. 

Bourget    recommends    the    following 

ointment : — 

^  Acidi  salicylici   gr.  xlv    (3  Gm.). 

Olei  tcrebinthince  ...    mxlv   (3  c.c). 

Adipis  lance  hydrosi, 

Adipis  bcnzoinati.  .3.3.  5v   (20  Gm.). 

Fiant  unguentum. 

Sig.:  To  be  applied,  and  covered  with 
absorbent  cotton  and  an  impervious  ma- 

Baker  finds  the  following  collodion 
useful  in  relieving  pain  : — 

I^  Phenylis  salicylatis 3j  (4  Gm.). 

Mthcris  f5i   (4  c.c.) . 

Collodii  ill    (30  c.c). 

M.  Sig.:  To  be  painted  on  the  affected 
joints  twice  daily  or  oftener. 

Arendt  praises  a  formula  contain- 
ing ichthyol : — 

R  Ichthyolis    3iiss  (10  Gm.). 

Alcoliolis  dilttti fSiiss    (10  c.c). 

Aqu<u  destillatcc   f3x  (40  c.c). — M. 

Robinson  has  found  the  following 
ointment  so  efficient  as  to  permit  of 
dispensing  with  internal  treatment 
altogether : — 

B  Mentholis   3j  (4  Gm.) . 

Methylis  salicylatis   ....    f3j   (4  c.c). 

Acidi  salicylici    3ij    (8   Gm.). 

Alcoholis   q.  s.  ad  fjj    (30  c.c). 

M.  Sig.:  Paint  jomts  briskly  with 
camel's-hair  brush,  cover  with  absorbent 
cotton  and  oiled  silk,  and  bandage  snugly 
but  not  tightly. 

When  the  epidermis  begins  to  peel 
an  emollient  ointment  should  be  sub- 
stituted for  a  day  or  two. 

Sixteen  cases  of  acute  rheumatism 
treated  l)y  typhoid  vaccine,  used  only 
as  a  standardized  foreign  protein. 
Sixteen  minims  (1  c.c.)  were  given  in- 
travenously daily  until  a  cure  had 
been  obtained.  The  treatment  is 
justifiable  where  apical  abscesses,  in- 
fected tonsils,  gall-bladder,  appendix, 
or  genitourinary  tract  can  be  demon- 
strated and  removed,  and  in  those  re- 
fractory to  other  treatment.  Lyter 
(Jour.  Amer.  Med.  Assoc,  Jan.  5,  1918). 
Excellent  results  from  hypodermic 
injections,  once  daily,  of  150  c.c. 
(5  ounces)  of  a  solution  of  7  Gm. 
(108  grains)  of  sodium  chloride  and 
10  Gm.  (155  grains)  of  sodium  sul- 
phate in  a  liter  (18  ounces)  of  water. 
It  is  seldom  necessary  to  give  more 
than  3  or  4  doses  to  obtain  marked 
improvement.  S.  L.  Brian  (La  Sem- 
ana  Med.,  June  6,  1918). 

Subcutaneous  injection  of  oxygen 
systematically  used  in  thousands  of 
patients  with  rheumatism,  mostly 
subacute  and  chronic.  It  is  a  power- 
ful adjuvant  to  other  measures.  The 
writer  usually  injects  100  c.c.  (3% 
ounces)  at  the  site  of  the  pain,  some- 
times injecting  all  the  larger  joints  at 
1  sitting,  using  up  2,  4,  or  more  liters. 
An  elderly  woman  with  chronic  nodu- 
lar rheumatism  for  two  years  in  hands 
and  knees  was  relieved  of  all  pain 
and  inflammation  by  8  injections. 
The  oxygen  was  injected  into  the 
dorsum  of  the  hands  and  massaged 
into  the  fingers.  Zabaleta  (Siglo  med- 
ico, Aug.  10,  1918). 

In  subacute  and  chronic  rheuma- 
tism several  writers  advise  the  use  of 
a  Z2)  per  cent,  ichthyol  ointment  or  a 
20  per  cent,  ichthyol-glycerin  solu- 
tion, aided  by  ichthyol  and  iodides  in- 
ternally.     Salicylic    cataphoresis    has 

also  1)een  used. 

Report  of  rapid  cure  of  acute  rheu- 
matism after  intra-articular  injections 
of  sodium,  salicylate  by  the  catapho- 
retic  method.    Similar  cases  reported. 



Wullyamoz    (Brit.    Med.    Jour.,    Aug. 
13,  1910). 

Occasionally    cases    of   rheumatism 
are  met  with  in  which   the  pains  do 
not  yield  to  sodium  salicylate  and  yet 
promptly  yield  to  acetylsalicylic  acid 
(aspirin).     Internal  administration  of 
salicylates  frequently  fails  to  give  re- 
lief to  the  pain  experienced  about  the 
fibrous     tissues,     notably    under    the 
heels  in  patients  who  have  had  a  pre- 
vious  attack  of  acute  articular  rheu- 
matism.    In   such  cases  the  local  use 
of  oil  of  wintergreen,  1  dram  (4  Gm.) 
to  an  once   (30  Gm.)   of  lanolin,  will 
generally  give  relief.     The   same  ap- 
plies to  the  pain  accompanying  acute 
rheumatic     pleurisy     or     pericarditis. 
For  painful   conditions   about  fibrous 
structures   the   addition  of  from  3   to 
5  grains  (0.2  to  0.3  Gm.)  of  potassium 
iodide  to  the  sodium  salicylate  often 
proves  beneficial.     Joint   effusions  of 
rheumatism  are  responsive  to  salicy- 
lates in  proportion  to  the  absence  of 
mechanical    irritation    by    movement. 
In  erythema  nodosum  local  treatment 
with  oil  of  wintergreen  brings  marked 
relief    of    the    pain    and    probably    a 
shortened  duration  of  the  attack.     A. 
F.    Voelcker    (Clin.    Jour.,    Aug.    16, 

The  writer  recommends  in  the 
treatment  of  light  attacks  of  rheuma- 
tism, as  well  as  in  sciatica,  gout,  and 
neuralgias  in  general,  the  following: — 

Acidi  salicylici   10  Gm.  (2^  dr.). 

Olei  terehinthin.(c   ...  SO  Cc.   (1%  oz.). 
Sulphuris  pnecipitati.  40  Gm.   (l^/^  oz.). 

M.  ft.  lotio. 

The  salicylic  acid  is  dissolved  in  10 
Gm.  (2^  drams)  of  the  turpentine, 
the  sulphur  mixed  with  the  remainder, 
and  the  two  portions  then  mixed. 
After  the  preparation  has  been  ap- 
plied to  the  skin,  it  is  covered  with  a 
layer  of  impermeable  tissue  held  by 
a  bandage.  When  the  dressing  has 
been  allowed  to  remain  for  three  or 
four  days  the  skin,  on  its  removal, 
will  be  found  to  have  become  de- 
tached from  the  deeper  layers.  Un- 
less the  patient  is  sensitive,  the 
preparation    may    be    applied    again. 

Otherwise,  it  is  well  to  use  a  zinc 
paste.  Scharff  (Therap.  Monats., 
Feb.,  1912). 

Excellent  results  obtained  by  apply- 
ing externally  a  mixture  of  2  parts 
of  ground  camphor  and  1  part  of 
phenol,  adding  5  per  cent,  alcohol  to 
the  mixture.  The  result  is  an  oily 
fluid,  sparingly  soluble  in  water,  and 
free  from  caustic  action.  Only  very 
delicate  skins  feel  a  slight  smarting. 
It  seems  to  be  especially  toxic  to 
streptococci.  V.  Chlumsky  (Zent- 
ralbl.  f.  inn.  Med.,  Mar.  9,  1912). 

In  children  the  salicylates,  also 
hold  first  place.  The  dose  must  l>e 
90  to  150  grains  (5.8  to  9.7  Gm.)  in 
divided  doses  at  short  intervals  dur- 
ing the  first  24  hours,  with  a  nearly 
equal  amount  of  sodium  bicarbonate. 
Later  the  dose  may  be  lessened.  If 
the  case  responds  at  all  the  fever 
and  pain  subsides  in  48  hours.  In 
some  cases  morphine  must  be  given. 
The  joints  may  b-e  wrapped  in  ■  cot- 
ton or  local  applications  of  lead  water 
and  laudanum,  magnesium  sulphate 
or  oil  of  gaultheria  made.  A  splint 
may  be  applied.  Abundance  of  water, 
lemonade  and  orangeade  should  be 
given.  The  food  should  be  in  the 
form  of  milk  or  milk  products, 
cereals  and  broths.  Rarely,  a  stock 
vaccine  has  proved  beneficial.  Dis- 
eased tonsils  should  be  removed. 
Riesman  (Trans.  Phila.  Co.  Med.  Soc; 
Med.  Rec,  Apr.   16,   1921). 

Where  the  joint  pain  remains 
severe  in  spite  of  salicylates,  Dover's 
powder  may  be  ^8:iven ;  or,  particu- 
larly at  nig^ht,  an  injection  of  mor- 
phine may  become  necessary. 

The  complications  of  acute  articu- 
lar rheumatism  should  be  treated  ac- 
cording to  the  nature  and  the  indi- 
cations of  each.  Hyperpyrexia  and 
cerebral  rheuinatism  may  necessitate 
the  application  of  tepid  and  even 
cold  baths  combined  with  large  doses 
of  antipyretics;  the  cold  baths  or  cold 
pack  should  be  begun  as  soon  as  the 



temperature  starts  to  rise  quickly 
above  105°  F.  (40.5°  C),  otherwise 
considerable  danger  to  life  may  be 
entailed.  Upon  the  advent  of  endo- 
carditis the  use  of  the  ice-bag  or  pre- 
cordial blistering  should  be  availed 
of,  and  digitalis  may  have  to  be  em- 

A  persistently  high  pulse  rate  in 
acute  articular  rheumatism  is  always 
to  be  regarded  as  indicative  of  myo- 
cardial involvement,  and  as  long  as 
it  continues  absolute  rest  is  essential. 
Rest  in  bed  should  be  persisted  in  as 
long  as  six  months  to  a  year  if  the 
physical  signs  indicate  that  the  heart 
has  not  recovered  completely.  Dur- 
ing the  acute  stages  of  the  disease 
the  pain  may  make  the  patient  very 
restless.  Under  these  circumstances 
an  ice-bag  may  be  applied  over  the 
heart,  and  sleep  should  be  obtained 
by  the  use  of  morphine,  since  the 
other  hypnotics  do  not  sufficiently  re- 
lieve pain  to  permit  rest.  If  the 
patient  has  not  much  pain,  but  is 
nevertheless  restless,  the  bromides 
are  of  no  value.  When  the  heart  re- 
mains persistently  weak,  and  suffi- 
cient time  has  elapsed  for  inflamma- 
tory processes  to  quiet  down,  minute 
doses  of  digitalis  and  arsenic,  contin- 
ued over  a  long  period,  are  often  of 
value.  Turnbull  (Austral.  Med.  Jour.; 
Therap.  Gaz.,  Nov.  15,  1911). 

When  the  fever  declines,  but  one 
or  more  articulations  remain  swollen 
and  painful,  it  has  been  recommended 
to  employ  bandaging  for  some  time. 
Also,  baths  in  hot  water  or,  better, 
hot-air  baths,  will  in  many  cases 
bring  relief.  Massage  is  likewise  a 
valuable  measure. 

Iron  is  usually  a  useful  remedy 
during  convalescence,  in  view  of  the 
rapid  anemia  induced  by  the  disease. 
With  it  may  be  coupled  quinine  and 
strychnine.  Arsenic  may  also  be  of 
value.  A  generous  diet  should  be 

In  rheumatic  conditions  associated 
with  anemia  and  in  sore  throat  of 
rheumatic  origin,  following  mixture 
recommended:  Dissolve  1  dram  (4 
Gm.)  of  sodium  saUcylate  in  2  ounces 
(60  c.c.)  of  water.  Add  liquor  ferri 
perchloridi,  plus  an  ounce  of  water, 
giving  dark-purple  mixture.  Then 
add  1  dram  of  potassium  bicarbonate 
dissolved  in  1  ounce  (30  c.c.)  of  water, 
and  fill  up  bottle  to  8  ounces  with 
water.  Drinkwater  (Liverpool  Med- 
ico-Chir.  Jour.,  July,  1911). 

No  treatment  has  been  found  able  to 
prevent  surely  the  complications  or  re- 
currence, but  most  authors  agree  that 
the  use  of  salicylates  in  sufficient  doses 
continued  for  some  time  after  the  re- 
turn of  normal  temperature  gives  the 
best  results  in  both  respects. 

Cases  showing  the  possibility  of 
treatment  with  colloidal  sulphur,  of 
cutting  short  an  oncoming  chronic 
rheumatic  state  following  attacks  of 
acute  rheumatism.  The  patient  was 
completely  relieved,  resuming  his  oc- 
cupation in  three  months,  in  spite  of 
several  interruptions  in  the  treatment. 
The  solution  of  colloidal  sulphur  em- 
ployed contained  0.2  Gm.  (3  grains) 
of  sulphur  to  every  15  c.c.  (^  ounce), 
and  was  given  in  doses  of  1  teaspoon- 
ful  before  breakfast  and  supper,  grad- 
ually increased  to  1  tablespoonful. 
The  solution  was  rendered  palatable 
with  sugar  and  an 'aromatic  prepara- 
tion. Sodium  salicylate,  having  no 
efifect  on  the  pain  or  in  preventing 
recurrence  of  subacute  attacks,  may 
be  advantageously  replaced  by  qui- 
nine sulphate  in  the  dose  of  5  grains 
(0.3  Gm.)  twice  a  day.  A.  Robin  and 
L.  C.  Maillard  (Bull,  de  I'Acad.  de 
Med.,  Nov.  25,  1913). 

The  writer  regards  all  arthritic  in- 
flammation as  microbic,  and  90  per 
cent,  of  the  cases  are  due  to  strepto- 
cocci. Acute  inflammatory  rheuma- 
tism, chronic  , articular  rheumatism, 
and  arthritis  deformans  are  but  dif- 
ferent manifestations  of  one  cause, 
modified  by  individual  susceptibility, 
both    constitutional    and    local,     and 



duration  of  disease.  He  reports  suc- 
cessful treatment  of  chronic  rheuma- 
tism by  means  of  autogenous  vac- 
cines. The  preferable  source  for 
these  is  the  pharynx.  The  benefit 
from  vaccine  ranged  from  total  cure 
in  the  mild  cases,  to  disappearance 
of  all  symptoms  except  transitory 
slight  stiffness  in  the  most  severe. 
Greeley   (Med.  Rec,  June  13,   1914). 

Where  a  case  persists  over  many 
weeks,  a  focus  of  infection  in  the  ton- 
sils, nasal  sinuses,  ears,  or  elsewhere  in 
the  body  should  be  sought.  Tonsillec- 
tomy may  be  required. 

The  writer  deprecates  the  general 
tendency  to  refrain  from  operating  on 
inflamed  tonsils  associated  with  acute 
joint  involvement.  There  may  be 
greater  danger  in  deferring  operation 
too  long.  If  the  tonsils  are  the  source 
of  infection,  their  continued  presence 
increases  the  danger  of  secondary  in- 
volvement of  the  heart.  Tonsillec- 
tomy is  indicated  as  soon  as  the  acute 
tonsillar  inflammation  sul)sides.  Sali- 
cylates in  large  doses  should  be  used 
to  allay  joint  pains  before  operating. 
With  intensive  salicylic  treatment 
the  writer  also  gives  sterile  milk  sub- 
cutaneously,  thus  producing  hyper- 
emia of  and  exudation  over  the  in- 
volved structures.  The  rheumatic 
process  is  controlled  in  a  few  days. 
Of  70  cases  treated,  none  developed 
pericarditis,  and  but  2  a  cardiac  lesion. 
The  treatment  succeeds  where  sali- 
cylate treatment  alone  seems  ineffec- 
tive. Endocarditis  is  favorably  influ- 
enced by  intramuscular  injections  of 
10  c.c.  (2;/  drams)  of  sterile  milk. 
A.  Edelmann  (Miinch.  med.  Woch., 
Dec.  18,  1917). 

Nephritis  plays  the  chief  role  in 
causing  senile  rheumatism.  If  the 
patient  is  robust  the  writer  gives 
Seidlitz  mixture  or  magnesium  citrate 
before  breakfast;  if  frail,  a  compound 
cathartic  pill  at  bedtime.  Cabinet 
baths  once  or  twice  a  week  are  very 
beneficial.  Salicylates  irritate  the 
kidneys.  Heroine  usually  relieves 
the  pain  in  acute  cases.  Superheated 
air  at  130°,  180°,  or  200°  C.  is  applied 

to  cases  with  a  tendency  to  defor- 
mity. Sodium  succinate,  10  grains 
(0.6  Gm.)  every  three  hours,  is  often 
of  great  value.  Senile  rheumatism 
improves  on  exercise.  M.  W.  Thewlis 
(Med.  Rev.  of  Reviews,  June,  1918). 


Muscular  rheumatism,  or  myalgia,  is 
an  affection  of  the  muscles  and  the  re- 
lated fasciae,  causing  pain  and  stiffness, 
which  usually  disappear  after  some 
days.  It  sometimes  assumes  chronicity, 
being  then  accompanied  by  the  forma- 
tion of  fibrous  bands  and  nodules  in 
the  muscles. 

SYMPTOMS.— The  principal  symp- 
tom is  pain,  which  may  be  spontaneous 
or  caused  by  movements  or  pressure  of 
the  diseased  parts.  The  pain  in  some 
cases  remains  limited  to  the  muscles 
first  affected,  but  sometimes  it  suddenly 
disappears  from  these  and  attacks  an- 
other group  of  muscles.  Slight  fever 
sometimes  attends  the  affection.  The 
symptoms  vary  according  to  the 
muscles  affected.  In  rheumatism  ot 
the  intercostal  muscles — pleurodynia — 
(sometimes  with  involvement  of  the 
pectorals  or  the  serratus  magnus), 
breathing  is  painful  and  the  disease 
may  be  confounded  with  pleurisy. 
Localized  tenderness  may  exist  over 
the  involved  muscles.  When  the  mus- 
cles of  the  abdominal  wall  are  affected, 
there  is  excessive  tenderness  to  pressure, 
and  the  symptoms  may  resemble  those 
of  acute  peritonitis ;  but  the  absence  of 
fever  is  of  great  value  as  a  diagnostic 
sign.  Rheumatism  of  the  muscles  of 
the  back  occasionally  gives  rise  to  opis- 
thotonos, and  suspicion  of  spinal  men- 
ingitis may  arise.  Lumbago,  or  in- 
volvement of  the  lumbar  muscles,  may 
completely  incapacitate  the  patient,  and 
may  simulate  disease  of  the  sacroiliac 
joint,    vertebrae,   etc.      Rheumatism    of 



the  muscles  of  the  neck  causes  stiffness, 
and,  when  the  muscles  of  one  side  only 
are  affected,  rheumatic  torticollis  (wry- 
neck) is  produced.  The  sternomastoid 
muscle  may  become  prominent  as  a 
tense,  tender  cord,  and  rotates  the  head 
toward  the  involved  side. 

Pleurodynia  can  be  distinguished 
from  pleuritis  by  the  absence  of  a  fric- 
tion rub,  and  from  intercostal  neuralgia 
by  the  absence  of  the  characteristic 
tender  or  painful  spots,  and  by  the  fact 
that  the  pain  does  not  strictly  follow 
the  course  of  the  intercostal  nerves. 

The  acute  form  of  muscular  rheuma- 
tism passes  away  in  a  few  days.  The 
chronic  form  may  continue  for  weeks 
and  months  and  often  provokes  forma- 
tion of  new  connective  tissue,  with  its 
consequences — stiffening  of  the  muscles 
and  contractures.  Sometimes  small 
fibrous  bands  and  nodules  are  formed 
in  the  muscles  and  give  rise  to  much 
pain  and  tenderness. 

Rheumatism  of  the  muscles  is  in 
some  cases  complicated  Avith  myositis, 
which  may  be  general  or  localized, — 
limited,  for  instance,  to  the  muscle  of 
the  heart. 

Muscular  rheumatism  is  a  danger- 
ous diagnosis  for  a  conscientious 
physician  to  make.  The  correct  diag- 
nosis may  be  either  aortic  aneurism, 
cancer  of  the  pleura,  tabes,  osteomye- 
litis, spondylitis  deformans,  bone  tu- 
berculosis, syphilitic  periostitis,  lead 
poisoning,  morphine  habit,  alcoholic 
neuritis,  trichinosis,  gonorrheal  sep- 
sis, onset  of  an  acute  infection 
(typhoid,  influenza,  variola,  arterior 
poliomyelitis,  meningitis),  intestinal 
autointoxication,  sacroiliac  joint  re- 
laxation, local  disease  of  muscle, 
hematoma  due  to  trauma,  hematoma 
following  vascular  change  (as  in  ty- 
phoid, sepsis,  jaundice),  muscular 
cicatrices  following  fibrous  myositis, 
atheroma  of  arteries  in  muscle  (as  in 
intermittent  claudication),  muscle  ab- 

scess, infarct,  gumma,  echinococcus 
cyst,  or  new  growth.  The  diagnosis 
of  muscular  rheumatism  must  be 
made  by  exclusion.  M.  A.  Rabinowitz 
(N.  Y.  Med.  Jour.,  July  12,  1913). 


— Overwork,  especially  when  combined 
with  exposure  to  cold  and  dampness, 
has  always  been  considered  as  the  com- 
mon cause  of  rheumatism  of  the  mus- 
cles. Many  persons  are  very  sensitive 
to  draughts,  and  readily  develop  the 
affection,  especially  upon  sudden  cool- 
ing after  physical  motion  sufficient  to 
cause  perspiration.  The  disease  com- 
monly occurs  after  the  thirtieth  year, 
but  is  also  observed  before  tliat  aee. 
The  disease  is  very  liable  to  recur  in 
muscles  which  once  have  been  affected 
by  it;  especially  in  the  muscles  of  the 

In  all  probability  the  muscular  form 
of  rheumatism,  like  the  articular  form, 
is  caused  by  micro-organisms,  but  their 
presence  in  the  affected  muscles 
has  as  yet  not  been  proved  by  direct 

The  pathological  condition  pro- 
duced is  believed  to  be  chiefiy  an  in- 
flammation of  the  fibrous  investment 
of  the  muscle  fibers,  the  attachments 
of  the  muscles  to  periosteum,  and  the 
fasciae  surrounding  them.  Stress  is  laid 
by  some  on  disturbance  of  the  sensory 
nerve  endings  in  the  muscles. 

J.  Madison  Taylor  states  that  fibro- 
myositis  is  often  a  common  factor  in 
many  states  variously  named  where 
either  pain,  tenderness,  or  lameness  is 
a  feature.  It  may  not  be  painful, 
merely  a  latent  tenderness.  It  is 
often  superadded  to  other  causes  of 
disability,  complicating  and  obscuring 
them;  is  only  to  be  differentiated  by 
expert  tactile  exploration ;  the  condition 
should  be  remedied  to  permit  exact 



diagnosis.  The  site  can  usually  be 
located  and  evaluated  by  alterations 
in  the  local  density,  tension,  mobility 
or  restriction  of  motion.  Nodes  are 
often  minute  but  characteristic. 

Nearly  always  diagnostic  light  is 
afforded  by  definite  tenderness  and 
morphological  alteration  in  paraverte- 
bral structures  corresponding  to  the 
origin  of  the  sympathetic  innervation 
at  the  site  of  the  subsidiary  centers  in 
the  spinal  cord. 

TREATMENT.— For  internal  use 
salicylic  acid  and  its  compounds  are 
much  employed  and  will  sometimes, 
though  not  in  all  cases,  bring  relief. 
When  the  salicylates  fail  to  effect  a 
cure,  tincture  of  colchicum,  potas- 
sium iodide,  or  mercury  may  be.  tried 
together  with  an  antigout  diet. 

Thiosinamine  at  times  checks  prog- 
ress of  chronic  rheumatism.  Daily 
dosage  of  0.06  to  0.1  Gm.  (1  to  1^ 
grains)  by  injection  or  ingestion  can 
be  safely  employed.  Renon  (Bull,  de 
I'Acad.  de  Med.,  Apr.  25,  1911). 

The  following  treatment  of  muscu- 
lar rheumatism  recommended:  (1) 
rest  in  bed;  (2)  liberal  diet  of  milk, 
eggs,  light  meats,  farinaceous  articles 
and  cruciferous  vegetables.  Butter- 
milk and  water  between  meals  ad  lib- 
itum; (3)  general  bath  daily,  with 
temperature  progressively  increased, 
followed  by  a  blanket  or  alcohol 
sweat;  (4)  massage,  after  pain  and 
tenderness  under  control  at  least 
twenty-four  hours;  (5)  in  lumbago  or 
other  localized  muscular  troubles 
where  general  methods  inefficient: 
acupuncture  or  injection  directly  into 
involved  muscle  of  10  c.c.  (2j/2  drams) 
of  ice-cold  normal  salt  solution;  (6) 
where  severe  pain:  salicylates,  at 
first  in  large  hourly  doses,  with 
sodium  bicarbonate.  Locally,  20  per 
cent  salicylic  acid  ointment  or  lini- 
ment of  oil  of  gaultheria,  followed  by 
flannel  jacket  or  bandages,  with  hot- 
water  bottles  or  electric  pads.  Meyer 
(N.  Y.  Med.  Jour.,  July  5,  1913). 

Externally,  tincture  of  iodine  and 
all  the  rubefacients — ammonia,  cam- 
phor, turpentine,  etc. — are  to  be  tried  ; 
also  warmth  in  the  form  of  hot  water, 
poultices,  and  hot  baths  (Russian  or 
Turkish).  Hot-air  baths  have  been 
much  recommended.  The  external 
use  of  methyl  salicylate  often  alle- 
viates the  pain.  Belladonna  plaster, 
chloroform  liniment,  and  the  galvanic 
current  may  also  be  used  for  this  pur- 
pose. Massage  may  completely  cure 
a  recent  case.  Rest  of  the  affected 
muscles  should  be  procured  by  all 
means  possible.  In  pleurodynia 
strapping  the  side  with  adhesive 
plaster  generally  affords  marked  re- 
lief. In  lumbago  as  well  as  in  pleu- 
rodynia light  application  of  the 
Paquelin  cautery  is  frequently  of 
marked  value.  Otto  has  recom- 
mended a  single  injection  of  7^  to 
15  grains  (0.5  to  1  Gm.)  of  freshly 
obtained  sodium  iodate  in  5  per  cent, 
solution  at  the  site  of  pain.  Sajous 
injects  normal  saline  solution  sub- 
cutaneously — 2  fluidounces  (60  c.c.) 
■ — daily  and  gives,  besides  sodium 
salicylate  and  sodium  carbonate  (not 
bicarbonate)  in  full  doses,  watching 
the  heart  carefully. 

Injection  of  5  or  10  c.c.  (80  to  160 
minims)  of  salt  solution  into  the 
muscle  at  the  most  painful  point  will 
frequently  relieve  the  pain,  though,  of 
course,  it  has  no  effect  upon  the 
cause.  Schmidt  (Med.  Klinik,  vi, 
131,  1910). 

The  chief  measure,  other  than  rest 
in  bed,  in  the  treatment  of  muscular 
rheumatism  is  the  application  of  heat 
in  the  form  of  fomentations,  poultices, 
and  hot-water  bags.  Dry  cupping 
over  the  tender  region  one-half  hour 
twice  or  thrice  daily  is  very  beneficial. 
One  or  two  electric-light  bulbs  placed 
six  inches  from  the  affected  part,  a 
piece  of  asbestos,  tin  or  woolen  ma- 
terial encircling,  so  as  to  concentrate 


the  heat,  will  produce  a  useful  hyper-  den  and  severe  strain  on  tendons  and 

emia;  the  skin  should  be  protected  by  ligaments;  (4)  absorption  of  irritating 

anointing  with  petrolatum.    The  elec-  toxins  from  the  alimentary  tract;  (5) 

trie-light   baking   apparatus   is,    how-  tonsillitis  and  pharyngitis;    (6)    influ- 

ever,    more    serviceable.     This    treat-  enza;  (7)  febricula.     The  forms  most 

ment  the  author  has  found  verj'  bene-  commonly    seen    are:     (1)    muscular 

ficial,    together    with    light    massage,  rheumatism,  involving  especially  the 

after  which  a  woolen  cloth  is  placed  muscles    of    the    neck,    those    of    the 

over  the  hypercmic  area.     He  has  also  shoulder    and    upper    arm     (brachial 

found  serviceable  light  massage  with  fil)rositis),  the  intercostal  muscles,  or 

the  use  of  an  analgesic  lubricant: —  the   lumbar  muscles    (lumbago);    (2) 

B  MenthoVis  Dupuytren's  contraction;  (3)  fibrositis 

Camphom.Az   ?i-ij    (4  to  8  Gm.).  of  the  plantar  fascia;    (4)   pads  upon 

Chlorali    hx-  finger-joints,   usually   confined   to   the 

drati   3ss-j    (2  to  4  Gm.).  dorsal  aspects  of  the  proximal  inter- 

Olei  gaultlie-  phalangeal  joints,  and  apparently  un- 

■yi^cc    5ii-iv   (8  to  15  Gm.).  related    to    rheumatoid    arthritis,    or 

Adipis  lance  h\<-  gout.      In    chronic    villous    synovitis, 

drosi    ......  Bi-ij   (30  to  60  Gm.).  though   strictly  not  a  form  of   fibro- 

M,    r,                  .  sitis,    the    correct   treatment    is    simi- 

.  et  ft.  unguentum.  ,       '        ,           ^     , 

lar   to    that   of    the    other    conditions 

After  the  patient  is  able  to  be  out  mentioned.    It  is  purely  local,  usually 

of    bed    a    suitable    adhesive    plaster  occurs  in  the  knee,  and  characterized 

dressing  will  allow  him  to  walk,  with  ^^y  crepitus  or  creaking  on  movement, 

slight  muscular  fixation.     J.  H.  Shaw  ^^^  by  p^j^   ^nd  tenderness  on  use. 

(N.  Y.  Med.  Jour.,  July  5,  1913).  j^  j^e  treatment  of  an  acute  fibro- 

When  the  disease  has  passed  over  sitis,  a  saline  aperient  should  always 

to    the    chronic    sta-e    further    use    of  be  given  at  the  onset  of  the  attack. 

,      -        \   .        .     ,          r    •   1  snd    repeated    as    necessary.      Saucy- 

massage  and  electricity  is  beneficial.  j^^^^    ^^^    ^^    jj^^j^    ^^^^^^.^^^    ^,^1^^^ 

Iodine    ointment    may    be    used    with  though  aspirin  is  of  decided  use  for 

benefit.     In  cases  attended  by  indura-  the    relief    of    pain    in    severe    cases, 

tion  and  fibrous  nodules  in  the  mus-  Potassium    iodide    should    always,    if 

cles,    characterized    often    by    contin-  possible,  be  given  in  full  doses  of  10 

,               .                      ...  or  12  grams   (0.6  or  0.//   Gm.),  com- 

uous  and  very  intense  pain,  excision  i  •     ^     vu  ^     •           i        „„^  „«r^,v, 

-^                                         .  bined  with  tonics  such  as  nux  vomica 

of  the  hard  nodules  of  fibrous  tissue  or  the  compound  glycerophosphate 
often  gives  immediate  relief.  syrup.  If  symptoms  of  iodism  result, 
Chronic  fibrositis  is  generally  la-  iodipin  may  be  tried.  Fibrolysin  was 
belled  "rheumatic,"  but  undoubtedly  employed  in  several  cases  of  thicken- 
not  a  sequel  of  acute  rheumatism,  and  "^S  and  contraction  of  fibrous  tissues 
in  no  sense  connected  with  it;  the  es-  i"  different  forms  of  fibrositis  and 
sential  pathological  change  is,  in  arthritis,  as  well  as  in  several  cases 
general,  an  inflammatory  hyperplasia  o^  Dupuytren's  contraction,  with  good 
of  the  white  fibrous  tissue  in  various  results  in  about  two-thirds  ot  the 
parts  of  the  body.  Such  aflfections  cases.  It  should  be  injected  under 
cause  pain  and  stiffness,  the  former  strict  antiseptic  precautions  into  the 
aggravated  by  any  sudden  movement.  ^eep  subcutaneous  tissues  of  the 
Recurrence  is  common  and  if  not  suit-  "PP^^"  a™'  ^ach  <.rm  being  injected 
ably  treated,  the  thickened  fibrous  alternately.  It  is  necessary  to  give 
tissue  remains  as  indurations  in  30  to  40  injections  in  all,  and  they 
various'  situations.  The  commonest  should  be  administered  on  alternate 
causes  of  local  fibrositis  are:  (1)  cold,  days.  After  20  injections  have  been 
damp,  and  wet;  (2)  extremes  of  heat  '  given  movements  and  massage  of  the 
and  cold;  (3)  local  injuries,  as  by  sud-  affected     fibrous     tissues     should     be 



commenced.  In  the  treatment  of  pads 
upon  the  finger-joints  the  only  pro- 
cedure found  useful  besides  fibroly- 
sin  was  the  nightly  inunction  of  a  25 
per  cent,  iothion  ointment.  In  the 
early  stages  of  an  acute  fibrositis  hot 
fomentations  are  useful.  Afterward 
one  of  the  best  external  applications 
is  a  mixture  of  equal  parts  of  chloral 
hydrate,  camphor,  and  menthol.  The 
resulting  liquid  should  be  painted  over 
the  painful  area,  and  then  gently  rub- 
bed in  with  the  fingers.  Another  use- 
ful procedure  is  to  paint  the  painful 
area  with  tincture  of  iodine  and  then 
apply  a  hot  linseed  poultice  or  very 
hot  fomentation.  In  the  latter  stages 
the  aconite,  belladonna,  and  chloro- 
form liniment  applied  on  lint  is  fre- 
quently most  beneficial.  In  a  very 
localized  fibrositis  counterirritation, 
especially  by  the  thermocautery,  is 
sometimes  of  great  use.  Rest  of  the 
affected  parts  and  diaphoresis  are  two 
of  the  most  important  procedures  in 
the  treatment,  the  latter  being  es- 
pecially beneficial  at  the  onset  of  the 
attack.  Heat  is  of  great  value,  and 
if  employed  early  will  frequently 
abort  an  attack.  If  it  is  to  be  applied 
to  the  whole  body  the  electric-light 
cabinet  is  most  convenient  and  val- 
uable. In  lumbago  and  chronic  vil- 
lous synovitis  of  the  knees,  the  most 
eflfective  local  treatment  is  super- 
heated air,  applied  for  fifteen  or 
twenty  minutes,  immediately  followed 
by  ionization  (cataphoresis)  for  ten 
to  fifteen  minutes.  In  chronic  joint 
cases  and  chronic  lumbago,  the  author 
orders  for  ionization  a  2  per  cent, 
solution  of  lithium  iodide,  directing 
that  the  negative  ion  (the  iodine) 
should  be  driven  into  the  tissues.  In 
acute  lumbago  a  2  per  cent,  solution 
of  sodium  salicylate  should  be  used 
at  the  first  sitting  or  two  in  order  to 
relieve  the  pain.  In  the  later  stages 
of  a  muscular  fibrositis  a  rapidly  in- 
terrupted faradic  current  is  beneficial, 
but  it  should  be  so  weak  as  not 
to  cause  any  muscular  contraction. 
Massage  is  very  useful  in  the  later 
stages,  but  it  should  not  be  employed 
until  it  causes  no  pain,  and  should  be 

very  gentle  at  first.  During  the  pain- 
ful stage  of  muscular  rheumatism  rest 
of  the  affected  muscles  is  required, 
but  later  on  exercises  of  the  muscles 
are  of  great  benefit.  They  should  be 
performed  on  rising  in  the  morning 
and  followed  by  a  cold  or  tepid  bath 
and  brisk  rubbing  of  the  skin  with  a 
rough  towel.  No  special  dieting  is 
required;  moderation  should  be  the 
keynote.  Porous  linen  underwear  is 
the  most  suitable  for  rheumatic  indi- 
viduals. A.  P.  Lufif  (Lancet,  Mar.  12, 

The  distinguishing  pathological  fea- 
tures of  fibromyositis,  according  to  J. 
Madison  Taylor,  are  plastic  adhesions 
of  contiguous  structures  exerting 
compression  on  sensory  nerve-fibers 
which  need  to  be  set  free  mechan- 
ically. While  this  can  be  achieved  by 
various  agencies  such  as  by  counter- 
irritation,  blisters,  electricity,  etc.,  the 
most  radical,  prompt,  and  permanent 
relief  is  by  expert  manipulation,  such 
as  deep  pressures  with  lateral  traction, 
torsion,  etc. ;  the  best  is  by  lifting  and 
separating  the  adherent  structures, 
thus  freeing  sensory  fibers  from  com- 
pression. In  some  cases,  fibromyo- 
sitis is  so  persistent  as  to  remain  for 
many  years  a  source  of  disablement, 
lameness,  or  deformity,  resisting  all 
medication,  yet  can  be  removed  by 
manipulation  in  a  few  days.  Best  re- 
sults from  medication  by  sodium  ben- 
zoate  and  Martin  H.  Fisher's  alkaline 
solution  by  colonic  irrigation. 

In  any  of  the  ordinary  manifesta- 
tions of  chronic  rheumatism,  as  lum- 
bago, sciatica,  pleurodynia,  or  cepha- 
lalgia, and  with  any  obscure  myalgic" 
or  neuralgic  pain  in  any  part  of  the 
body,  a  careful  investigation  should 
be  made  of  the  fibromuscular  tissues 
of  the  affected  areas.  In  the  more 
recent  diffuse  cases  there  is  general 
tenderness  of  these  tissues.  Usually, 
either  with  or  without  such  general 
tenderness,  one  will  find  areas  which. 



are  definitely,  often  exquisitely,  ten- 
der to  touch.  General  treatment  for 
a  feverish  attack,  with  the  ordinary 
pain-relieving  drugs,  generally  suffices 
to  cure.  If  the  pain  is  at  all  localized 
a  single  thorough  application  of  mas- 
sage may  result  in  cure  in  this  early 
stage.  y\ny  discoverable  cause,  such 
as  gastrointestinal  irregularities,  must 
be  removed.  During  the  more  acute 
exacerbat'ons  sodium  salicylate  pi"o- 
duces  some  relief,  but  recurrence  is 
probable  indefinitely.  To  obtain  a 
permanent  cure  it  is  absolutely  nec- 
essary to  obtain  locally  a  complete 
dispersal  of  the  indurations.  Coun- 
terirritation  by  blistering  or  cau- 
tery produces  relief,  but  nothing  is 
so  efficient  as  the  rubbing  in  of  oil 
of  gaultheria..  Important  also  are 
massage  and  systematic  exercises. 
Acupuncture  is  of  great  use  in  reliev- 
ing pain,  but  does  not  produce  com- 
plete dispersal  of  the  infiltrations.  In 
cases  of  fibrous  nodules  w^hich  will 
not  yield  to  simpler  measures,  and 
which  by  pressing  on  nerves  cause 
persistent  pain,  excision  is  not  only 
advisable  but  necessary.  Telling 
(Lancet,  Jan.  21,  1911). 

Senile  rheumatism  described  as  a 
separate  morbid  condition.  Being 
one  of  the  manifestations  of  aging,  it 
can  neither  be  prevented  nor  cured. 
Pain  can,  however,  be  relieved.  The 
pain  usually  disappears  soon  after 
joint  motion  has  ceased,  but  if  it  per- 
sists, application  of  moist  heat,  fol- 
lowed by  an  inunction  of  2  per  cent. 
cocaine  liniment  or  ointment,  using 
an  animal  base,  will  generally  give 
relief.  Sweet  butter  is  an  excellent 
base  for  this  purpose.  To  prevent  its 
becoming  rancid  2  grains  (0.12  Gm.) 
of  sodium  benzoate  to  the  ounce  (30 
Gm.)  should  be  added.  The  constitu- 
tional measures  are  hygienic  and 
medicinal,  the  latter  consisting  of  the 
intermittent  use  of  phosphorus  and 
the  iodide  of  arsenic.  I.  L.  Nascher 
(Amer.  Med.,  Dec,  1911). 

The  writer  emphasizes  the  value  of 
local  heat,  especially  dry,  radiant 
heat,  combined  with  ionization,  in 
muscular    rheumatism.      In    lumbago. 

the  static  current  may  be  substituted 
for  ionization.  Massage  is  useful,  but 
it  should  not  be  applied  to  the  af?ccted 
part  itself,  but  around  it.  A.  P.  Luft 
(Med.  Rec,  Aug.  16,  1913). 


Gonococcal  rheumatistn,  or  arthritis, 
is  an  acute  inflammation  of  one  or 
more  articulations  occurring  during  the 
course  of  gonorrhea  and  caused  by  in- 
vasion of  gonococci  in  the  joints. 

SYMPTOMS.— The  condition  ordi- 
narily appears  in  the  acute  stage  of 
gonorrhea.  In  some  cases  the  lesion  of 
the  joints  is  only  revealed  by  arthralgia : 
i.e.,  intense  pain  without  swelling.  This 
condition  is  particularly  observed  in 
the  small  joints  of  the  foot.  The  pain 
is  worst  in  the  evening  and  is  aggra- 
vated by  movements.  The  arthralgia 
may  also  precede  the  evolution  of 
gonorrheal  arthritis  or  continue  for 
some  time  after  the  disappearance  of 
the  swelling. 

In  other  cases  the  affected  joint  be- 
comes the  seat  of  an  effusion  of  fluid, 
giving  rise  to  little  or  no  pain.  This, 
effusion  disappears  very  slowly,  and 
often  leaves  stiffness  or  fibrous  adhe- 
sions in  the  joint.  This  form  of  the 
disease  is  most  frequently  observed  in 
the  knee. 

Ordinarily  gonococcal  rheumatism  in 
its  mode  of  invasion  and  evolution  very 
much  resembles  the  acute  form  of  ar- 
ticular rheumatism.  It  differs  from 
that  disease,  however,  in  attacking  only 
one  or  a  few  articulations  at  the  same 
time,  and  in  that  the  affected  joints 
remain  involved  for  a  longer  period. 
Again,  gonococcal  arthritis  does  not 
migrate  so  suddenly  from  one  joint  to 
another  as  the  acute  articular  affection. 
No  joint,  however,  is  immune,  and 
even  those  which  ordinarily  escape  dur- 


ing  the  course  of  rheumatic  fever,  e.g.,  gonococcal  rheumatism  is  a  rare  occur- 

the  articulations  of  the  jaws  and  the  rence.    It  only  happens  when  the  infec- 

neck,  may  be  attacked  by  the  gonococ-  tion  with  gonococci  is  complicated  with 

cal  arthritis.  invasion  of  pyogenic  organisms.     The 

The  pain  is  of  extreme  intensity.    It  chronic  form  of  gonococcal  rheumatism 

is   aggravated   by   movements    and   by  often  gives  rise  to  contracture  of  the 

pressure  over  the  swollen  articulation,  joints  or  periostitis  of  the  epiphyses. 

Many   painful   points  are   also   found.  DIAGNOSIS. — The    diagnosis    is 

Tumefaction  is  ordinarily  very  marked ;  easy  when  the  urethral  discharge  is  still 

it  is  caused  both  by  effusion  into  the  present,    but    difficult    when    it   is    not. 

joint   and  by   edema  of   the   overlying  The   disease  may  be   confounded  with 

structures.     The  skin  over  the  affected  acute    articular    rheumatism   and   with 

joint  is  hot  and  tense.  osteomyelitis.  In  gonococcal  arthritis, 

Commonly  the  patient  tries  to  allevi-  but   few   articulations  are  attacked  at 

ate  the   pain  by  keeping  the   affected  once.    The  mode  of  development  of  the 

joint  semiflexed.     If  he  is  allowed  to  arthritis,  the  extent  to  which  the  periar- 

remain  in  this  position,  contraction  of  ticular  tissues  are  involved,  the  rela- 

the  extremity  may  result.  tive    absence    of    constitutional    symp- 

Gonococcal    rheumatism    does    not  toms,   the  inefficacy  of  the   salicylates, 

affect    the    articulations    alone.       The  and,  if  possible,  the  demonstration  of 

serous   bursse   and   the   sheaths  of   the  gonococci  in  the  blood  or  the  affected 

tendons  in  the  proximity  of  the  diseased  joint  constitute  the  chief  distinguish- 

joint  are   always   involved ;   sometimes  ing  features. 

they    alone    suffer,    the    inflammatory  ETIOLOGY.  —  Gonorrheal     rheu- 

process  being  thus  periarticular — gono-  matism  is  caused  by  an  infection  with 

coccal   tenosynovitis.     The   muscles  of  gonococci,   and  it   is   only  observed  as 

the  affected  extremity  are  always  af-  the  consequence  of  a  gonococcal  ure- 

fected  and  generally  become  atrophied,  thritis.     Many  authors  have  found  the 

In  some  cases  one  joint  only  is  at-  gonococci   in  material   taken    from  the 

tacked;  the  pain  is,  then,  as  a  rule,  still  affected  joints  or  synovial  sheaths,  and 

more    excruciating    and    the    effusion  some  have  even  observed  them,  in  the 

greater  than  in  the  polyarticular  form,  blood.     The  disease  attacks  both  sexes 

The  acute  stage  of  the  disease  is  not  equally;   it   may   occur   in    children   as 

usually  of  long  duration.     After  some  well  as  in  adults.     It  develops  in  2  per 

days  or  a  week  the  pain  declines  and  cent,  of  all  gonorrhea  cases  in  the  male 

the   effusion   diminishes.      The    disease  sex. 

rarely  disappears  completely,  however;  PROGNOSIS. — The    prognosis    as 

one  or  more   joints   remain   somewhat  to  life  is  good,  but  very  often  the  dis- 

stiff  and  painful  several  months.     The  ease  results  in  stift'ness  of  the  affected 

so-called  painful  heel  of  gonorrhea  is  joint  and  weakness  of  the  limb,  due 

the  result  of  a  periosteal  inflammation  to  atrophy  of  its  muscles. 

of  the  OS  calcis,  with  or  without  exos-  TREATMENT. — Treatment  by 

tosis.     In  some  instances  chronic  gono-  means    of    drugs    given    internally    is 

coccal  arthritis  assumes  the  form  of  a  not    of   great    value;    the    salicylates 

persistent  serous  effusion.  have    little    or    no    influence    on    the 

Suppuration  of  the  joints  affected  by  course    of   the    affection.      The    same 



appears  to  be  true  of  potassium 
iodide,  except  in  the  chronic  cases. 
Ihe  use  of  syrup  of  ferrous  iodide  in 
doses  of  10  to  60  minims  (0.6  to  4  c.c.) 
three  times  a  day  has  been  recom- 
mended by  J.  C.  Wilson.  Oil  of  gaul- 
theria  in  doses  of  from  5  to  20  drops 
every  two  hours  in  milk  has  also 
been  recommended,  \\niere  acute  or 
chronic  gonorrhea  coexists,  every 
means  should  be  taken  to  overcome 
the  urethral  focus  of  infection.  In 
the  more  chronic  cases  the  use  of 
tonics  such  as  strychnine,  arsenic, 
and  codliver  oil  may  prove  of  value. 
Gonococcus  vaccines  have  given 
excellent  results  in  a  certain  propor- 
tion of  chronic  cases.  Antigonococcic 
serum  lias  also  been  used. 

At  the  onset  of  gonorrheal  rheuma- 
tism, the  patient  should  receive  a 
purgative  of  calomel  to  be  followed 
by  citrate  of  magnesia,  or  salts,  or  a 
dose  of  castor  oil.  He  should  be  put 
on  a  light  diet  with  plenty  of  liquids, 
such  as  soup,  milk,  alkaline  waters, 
etc.,  avoiding  stimulating  articles  of 
diet  as  tea,  coffee,  spices,  and  alcohol. 
The  bowels  should  be  kept  regular 
and  the  patient  drink  plenty  of  water. 
H  necessary,  a  mild  diuretic  can  be 
given.  Codeine  or  morphine  should 
be  given  if  necessary  for  the  pain. 
Phenyl  salicylate,  S  grains  (0.3  Gm.) 
and  antipyrin,  3  grains  (0.2  Gm.) 
may  be  given  every  three  or  four 
hours  for  the  fever.  The  oil  of  gaul- 
theria  in  doses  of  20  drops  three 
times  a  day,  or  potassium  iodide, 
has  be:n  recommended.  Every  case 
should  be  treated  at  once  with  anti- 
gonococcic serum  or  gonococcic  vac- 
cine. The  combined  bacterins  seem 
to  be  more  useful  than  the  single- 
strain  cultures.  The  initial  dose  is  be- 
tween 10  and  20  million,  running  the 
same  up  every  second,  third,  or  fourth 
day,  until  about  50  million  are  being 
given  every  second  or  third  day.  Im- 
provement is  usually  noticed  within  a 
week  or  ten  days,  but  the  treatment 

should  be  continued  until  all  the 
symptoms  have  su])sided,  which  may 
take  from  four  to  six  weeks.  Broe- 
man  (Med.  Rev.,  Sept.,  1913). 

Local  treatment  is  of  great  impor- 
tance. The  affected  joint  should  be 
placed  on  a  splint  in  a  proper  position 
and  alxsolute  rest  of  the  extremity 
enjoined.  Pain  may  be  relieved  by 
various  anodyne  measures,  e.g.,  hot 
and  cold  applications,  tlic  ice-bag, 
ointments  of  ichthyol  or  belladonna, 
a  wet  dressing-  of  lead-water  and 
laudanum,  or,  if  necessary,  a  hypo- 
dermic injection  of  morphine.  Coun- 
terirritation  may  be  instituted  by 
means  of  turpentine  or  iodine. 
Gaucher  procures  relief  for  several 
hours  by  bathing  the  part  for  half  an 
hour  in  a  mixture  of  equal  parts  of 
an  aqueous  emulsion  of  black  soap 
and  of  oil  of  turpentine;  5  to  6 
fluidrams  (20  to  25  c.c.)  of  this  mix- 
ture are  used  with  6  gallons  (25 
liters)  of  water.  The  genitals  should 
be  anointed  vvith  petrolatum  before 
the  bath  is  administered.  Balzer 
uses  the  following  ointment: — 

IJ  Acidi  salicyiici. 

Old  tcrebinthin<c, 

Adipis  lance  hydrosi.aa  Siiss   (5  Gm.). 

Adipis  benzoinati   'Siij    (100   Gm.). 

Fiant  unguentum. 

In  the  intervals  between  local  pro- 
cedures a  bandage  should  be  applied 
as  firmly  as  is  practicable.  Or,  a 
plaster-of-Paris  dressing  may  be 
used  for  complete  immobilization, 
applied  under  anesthesia  if  necessary. 
Straightening  of  the  limb  under  anes- 
thesia is  necessary  if  fixation  in  a 
faulty  position  has  already  taken 

In  cases  in  which  acute  pain  has 
subsided  massage  and  passive  move- 
ments are  of  value  to  assist  in  res- 



toration  of  joint  mobility.  Dry  hot- 
air   baths,   Bier's   passive   hyperemia, 

and  counterirritation  with  bhsters  or 
the  thermocautery  are  also  very 
serviceable  measures  in  the  more 
chronic  cases.  The  last  two  pro- 
cedures are  especially  indicated  in 
cases  characterized  by  hydrarthrosis. 
Compression  is  also  of  value  in  these 

Where  the  above  fail  to  bring  re- 
lief within  a  reasonable  period,  and 
especially  if  the  effusion  becomes 
purulent,  arthrotomy  should  be  per- 
formed and  the  joint  evacuated  and 
irrigated  with  an  antiseptic  or  sterile 
saline  fluid,  according  to  indications. 
Aspiration  followed  by  injection  of  1 
to  l^A  fluidrams  (4  to  6  c.c.)  of  a 
1  :  4000  solution  of  mercury  bichloride 
has  been  recommended  by  P.alzer  and 
others,  but  the  more  radical  pro- 
cedure in  general  meets  with  greater 
favor.  Bres,  in  20  cases,  after  incis- 
ing the  joint,  removed  the  diseased 
synovial  membrane  and  injected 
dilute  tincture  of  iodine  or  a  weak 
solution  of  zinc  chloride.  All  his 
cases  recovered  completely. 

F.  Levison, 



L.  T.  DE  M.  Sajous, 



See  Joints,  Surgical  Diseases  of, 

RHIGOLENE.     See  Petroleum. 

SAL DISORDERS.     See  Index. 

RHUBARB.  —  Rhubarb,  or  rheum 
(U.  S.  p.),  is  the  root  of  Rheum  officinale 
and  of  other  undetermined  species  of 
Rheum  (nat.  ord.,  Polygonacc;c) :  a  plant 
indigenous  to  Asia  (China,  India,  Tar- 
tary,  and  Thibet),  but  which  is  cultivated 

in  America  and  elsewhere.  It  contains 
extractive,  sugar,  starch,  pectin,  lignin, 
salts,  several  unimportant  alkaloids,  a 
glucoside,  and  acids,  one  of  which,  chry- 
sophanic  acid,  is  used  in  medicine.  In 
commerce  two  sorts  are  recognized, — 
the  Chinese  and  the  European, — the  for- 
mer of  which  is  considered  the  better. 
It  occurs  in  irregular  cylindrical  or 
conical,  flattened  pieces,  which  are  gener- 
ally perforated,  are  covered  with  a  light 
yellowish-brown  powder,  and  have  fre- 
quently a  wrinkled  surface.  Beneath  the 
powder  the  color  of  the  root  is  reddish 
brown,  mottled  with  lighter  hues.  The 
root  is  dense  and  hard  and  has  a  bitter 
and  somewhat  astringent  taste  and  a 
peculiar  aromatic  odor.  When  chewed, 
the  root  is  gritty  (due  to  the  presence 
of  crystals  of  calcium  oxalate),  and  im- 
parts a  yellow  color  to  the  saliva. 
European  rhubarb  is  inferior  to  the 
Chinese  variety;  powdered  rhubarb  is  also 
inferior,  and,  if  not  adulterated,  at  least 
is  generally  made  up  of  inferior,  dam- 
aged,  worthless    or   worm-eaten    material. 

Rheum,  U.  S.  P.  (the  root).  Dose,  5  to 
30  grains   (0.3  to  2  Gm.). 

Extractum  rhei,  U.  S.  P,  (extract  of 
rhubarb).      Dose,   5    to    15    grains    (0.3    to 

1  Gm.). 

rUiidextractum  rhei,  U.  S.  P.  (fluid- 
extract  of  rhubarb).  Dose,  K  to  1 
dram    (1    to   4   c.c). 

Mistura  rhei  composita,  N.  F.  (rhubarb 
and  soda  mixture).  Fluidextract  of  rhu- 
barb, 15;  fluidextract  of  ipecac,  3;  bicar- 
bonate of  soda,  35;  glycerin,  350;  spirit 
of  peppermint,  35;  water,  sufficient  to 
make  1000  parts.     Dose,  1  to  4  drams  (4  to 

16  c.c). 

Pilulcc  rhei  compositce,  U.  S.  P.  (com- 
pound   rhubarb    pills,    containing   rhubarb, 

2  grains;     aloes,     V/2     grains;     myrrh,     1 
grain).     Dose,    1   to  3  pills. 

Pulz'is  rhei  coinpositus,  U.  S.  P.  (com- 
pound rhubarb  powder  or  Gregory's  pow- 
der, containing  rhubarb,  25;  magnesia, 
65;  ginger,  10  parts).  Dose,  ^  to  1 
dram  (2  to  4  Gm.). 

Syrupus  rhei,  U.  S.  P.  (syrup  of  rhu- 
barb, containing  fluidextract  of  rhubarb, 
10  per  cent.).  Dose,  2  to  6  drams 
(8  to  25  c.c). 



Syni/^us  rhei  aromaticus,  U.  S.  P.  (aro- 
matic syrup  of  rhubarb,  containinjif 
aromatic  tincture  of  rhubarb,  15  per 
cent.).     Dose,  2  to  6  drams  (8  to  25  c.c). 

Tinctura  rhci,  U.  S.  P.  (tincture  of  rhu- 
barb— rhubarb  20  per  cent.).  Dose,  Yz  to 
2  drams   (2  to  8  c.c). 

Tinctura  rhci  aromatica,  U.  S.  P.  (aro- 
matic tincture  of  rhubarb — rhubarl)  20  per 
cent.).     Dose,  K'  to  3  drams  (2  to  12  c.c). 

barb is  not  generally  considered  poison- 
ous, but  a  case  has  been  reported  in 
which  the  internal  administration  of 
rhubarb  gave  rise  to  a  hemorrhagic 
eruption  of  macules,  pustules,  and  blebs. 
The  mucous  membranes  were  also  af- 
fected, and  free  hemorrhage  from  the 
urethra    occurred. 

THERAPEUTICS.— Rhubarb  is  an  ex- 
cellent stomachic  tonic  in  atonic  dyspep- 
sia associated  with  deficient  biliary  and 
intestinal  secretion.  It  is  a  remedy  espe- 
cially adapted  to  those  of  relaxed  habit, 
but  inadmissible  when  an  hyperemia  of 
the  mucous  membrane  exists. 

Rhubarb  is  a  valuable  remedy  in  simple 
constipation,  where  we  wish  to  unload 
the  bowels  without  affecting  the  general 
system.  The  root  is  often  chewed  by 
adults  to  relieve  constipation.  In  chil- 
dren the  syrup  is  a  palatable  preparation 
for  this  purpose;  the  pill  or  compound 
pill   may   be   used    by   adults. 

Constipation  and  hemorrhoids  depend- 
ing upon  pregnancy  are  benefited  by  the 
administration    of    rhubarb. 

In  the  summer  diarrhea  of  children, 
with  green  stools,  the  aromatic  syrup  of 
rhubarb  may  be  employed  to  empty  the 
bowel  of  its  fermenting  contents  before 
giving  direct  treatment.  The  diarrhea  of 
indigestion  in  children  and  adults  is  re- 
lieved by  the  aromatic  syrup  or  by  the 
mixture  of  rhubarb  and  soda. 

In  children,  when  constipation  is  re- 
placed by  diarrhea,  if  any  ordinary  laxa- 
tive is  used,  rhubarb  is  an  available  rem- 
edy on  account  of  its  secondary  astrin- 
gent action. 

Functional  disturbance  of  the  liver  with 
deficient  biliary  secretion  is  relieved  by 
the  administration  of  rhubarb,  either 
alone  or,  better,  combined  with  blue  mass. 

Rhubarb   is   an   efficient   remedy   in   duo- 

denal catarrh  and  in  catarrh  of  the  biliary 
ducts  with  jaundice,  especially  in  chil- 
dren. White,  pasty,  or  clay-colored  stools 
and  a  skin  of  an  earthy  or  jaundiced  hue 
are    indications    for    rhubarb. 

RHUS  POISONING.       See   Der- 
matitis Venenata. 

RIES OF.     See  Index. 

RICKETS.       See  Bones,  Diseases 


RIGA'S  DISEASE.     See  Mouth, 
Lips,  and  Jaws,  Diseases  of. 


GUMS).— DEFINITION.— This  is  a 

pyogenic  inflammation  of  the  gums, 
apparently  starting  from  the  gum  mar- 
gins, and  associated  with  a  suppuration 
of  the  peridental  membrane  of  the 
roots  of  the  teeth,  which  tends  to 
loosen  the  latter  by  detaching  them 
from  the  surrounding  alveolar  tissue. 
SYMPTOMS.— The  earliest  symp- 
toms noted,  as  a  rule,  are  sensitive- 
ness, redness,  and  perhaps  swelling  of 
the  gums,  with  a  tendency  to  bleed 
when  touched.  The  development  of 
the  disease  being  insidious,  these 
signs  are  in  reality  those  of  an  ad- 
vanced morbid  process,  a  fact  shown 
in  many  cases  by  the  presence  of 
granular  pustules  around  and  under 
the  edges  of  the  gums,  due  to  the  for- 
mation of  deep  pockets  between  the 
latter  and  the  teeth.  An  offensive 
breath  and  a  coated  tongue  are  usual, 
and  periodical  attacks  of  toothache 
also,  though  in  some  cases  pressure 
over  the  gums  will  always  elicit  a  dull 
pain ;  occasionally  the  latter  becomes 
continuous.  Loosening  of  the  teeth 
in  their  sockets  occurs  quite  fre- 
quently. A  mild  stomatitis  is  some- 
times witnessed,  and  persistent  glos- 



sitis  with  irregular  exfoliation,  leaving 
red  patches,  may  also  occur. 

The  disease  is  obviously  a  chronic 
one,  but  it  may  be  attended  with  acute 
exacerbations  lasting  from  a  few  days 
to  several  weeks,  during  which  the 
gums  become  very  tender  and  bleed 
spontaneously.  During  the  ulcerative 
process  the  submaxillary  or  cervical 
glands  may  enlarge  and  become  pain- 
ful, suggesting  tuberculosis. 

Pyorrhea  alveolaris  is  not  infre- 
quently the  cause  of  systemic  dis- 

Many  cases  of  septic  fever  of  un- 
known origin  and  conditions  diag- 
nosed as  malignant  endocarditis,  as 
well  as  many  deaths  attributed  to 
acute  septicemia,  would  have  been 
correctly  diagnosed  if  the  oral  cavity 
had  been  examined.  Many  deaths 
due  to  alveolar  abscess,  tooth  extrac- 
tion, and  septic  oral  conditions  have 
been  reported. 

C.  H.  Mayo  interestingly  stamps 
pyorrhea  as  the  cause,  not  the  re- 
sult, of  systemic  disturbances.  Ap- 
pendicitis being  caused  by  septic  oral 
conditions  has  been  confirmed  by  the 
bacteriological  investigations  of  Lanz 
and  Tavel. 

Tooth  extraction  has  given  a  com- 
paratively high  death  rate.  All  cases 
presenting  pus  should  be  afforded 
free  drainage  until  danger  from  in- 
fection has  passed.  A.  W.  Fossier 
(N.  Y.  Med.  Jour.,  Aug.  7,  1915). 

Many  cases  of  alveolar  abscess  are 
erroneously  diagnosed  as  pyorrhea 
alveolaris.  This  grave  error  was 
much  more  common  before  the  ad- 
vent of  rontgenology.  It  has  been 
found  that  the  toxemia  resulting 
from  a  dental  granuloma  is  far 
greater  than  from  a  pyorrheal  dis- 
charge. M.  L.  Rhein  (Surg.,  Gynec. 
and  Obstet.,  Jan.,  1916). 

DIAGNOSIS.— The  differential 
diagnosis  is  sometimes  difficult  to 
establish  from  alveolar  disease  over- 
lying   necrosis    due    to    poisoning    by 

lead,    mercury,    phosphorus,    or    other 

elements   used   industrially.      Syphilitic 

or    tuberculous    lesions    of    the    gums 

may    also    cause    confusion.      Scurvy, 

now    rarely    encountered,    also    causes 

gingival     lesions     resembling     closely 

pyorrhea.     In  these  various  conditions 

the  history  of  the  case  and  the  course 

of  the  disease  are  frequently  of  major 

assistance   in   the   differentiation    from 

true  pyorrhea. 

Unlike  dental  caries  which  is  un- 
common in  "native"  races,  pyorrhea 
alveolaris  is  probably  as  common  in 
them  as  in  the  civilized.  It  is  very 
common  in  domesticated  animals, 
while  almost  unknown  in  wild  ani- 
mals. The  disease  has  increased 
enormously  in  civilized  countries  dur- 
ing the  last  few  decades.  Inefficient 
mastication,  whether  due  to  pre-exist- 
ing disease  of  the  teeth  or  to  the  food 
being  too  refined  and  soft,  is  a  power- 
ful etiological  factor.  Marginal  gin- 
givitis having  been  set  up,  infection 
with  organisms  rapidly  follows,  and  a 
rarefying  osteitis,  commencing  at  the 
inner  margin  of  the  sockets,  soon  sets 
in.  Lime  salts  from  the  pus  become 
deposited  on  the  roots  of  the  teeth, 
at  first  around  the  necks  just  under 
the  gum  margin,  and  later  on  the 
deeper  parts.  This  in  itself  acts  as 
an  irritant,  and  so  a  vicious  circle  is 
set  up  which  must  be  broken  before  a 
cure  can  be  effected — the  tartar  causes 
ulceration,  which  produces  more  pus, 
which  forms  more  tartar.  Gibbs 
(Edinb.  Med.  Jour.,  Oct.,  1917). 

ETIOLOGY.— Pyorrhea  alveolaris 
was  for  a  time  thought  to  be  due  to 
the  Endamcba  gingiz'alis  (Gros,  1849), 
but  later  work  seems  to  have  definitely 
shown  that  this  organism  cannot  be 
considered  the  causative  agent.  As  a 
matter  of  fact,  there  appear  to  be  both 
predisposing  causes  and  exciting  causes 
which  play  a  role  in  the  production  of 
pyorrhea.  Among  the  former  are  sys- 
temic diseases,    localized    malnutrition. 



frail  bony  investment  of  the  teeth,  and 
trauma  resulting  from  malocclusion 
(Merritt).  As  for  the  exciting  cause, 
it  seems  probable  that  anything  causing 
prolonged  irritation  of  the  gums  may 
act  as  such.  Bacteriological  studies  on 
the  disease  have  been  based  largely  on 
cases  in  a  frankly  purulent  state;  it  is 
considered  highly  probable,  however, 
that  a  non-purulent  inflammatory  stage 
of  the  condition,  due  to  trauma  and 
constitutional  influences,  may  occur  be- 
fore micro-organismal  infection  takes 

Such  constitutional  affections  as 
gout,  diabetes  mellitus,  and  other  states 
indicative  of  deficient  or  imperfecl 
metabolism,  while  incriminated  as  pre- 
disposing causes  of  pyorrhea,  are  by 
no  means  essential  in  its  production. 
According  to  Maurice  Roy,  unduly 
early  senile  absorption  of  the  bony 
tooth  sockets  constitutes  the  first  stage 
of  pyorrhea.  The  most  plainly  evident 
predisposing  cause  is  age.  After  the 
thirtieth  year  its  development  is  ob- 
served with  growing  frequency,  until 
about  the  fiftieth  year.  In  persons  who 
take  good  care  of  their  teeth  through 
cleanliness,  expert  attention  to  avoid 
cavities,  badly  fitting  crowns  or  fill- 
ings, etc.,  pyorrhea  tends  to  remain  in 
abeyance.  Its  harmful  eftects  are 
likely  to  follow  opposite  conditions, 
particularly  uncleanliness  and  trau- 
matisms of  the  gums  by  accumula- 
tion of  tartar,  especially  when  de- 
bilitating diseases,  such  as  gout, 
anemia,  and  infectious  diseases,  have 
weakened  the  bacteriolytic  activity  of 
the  buccal  secretions.  Autointoxica- 
tion of  intestinal  origin  is  also 
thought  to  favor  the  development  of 
the  disease,  possibly  by  overtaxing 
the  defensive  functions  of  the  body, 
thus     favoring     infection     from     any 

source.  It  may  likewise  occur  in  tooth- 
less gums  when  the  false  teeth  are 
not  kept  scrupulously  clean. 

There  is  a  frroup  of  cases  which 
the  writer  suspects  to  be  caused  by 
the  spirochete  of  Vincent's  angina. 
He  has  seen  several  cases  on  record 
where  mothers  have  developed  this 
condition,  and  it  has  been  followed 
by  an  illness  in  tlie  child,  first  diag- 
nosed as  diphtheria  and  then  as  Vin- 
cent's angina.  There  are  also  cases 
caused  by  the  Treponema  pallida.  W. 
Sterling  Hewitt  (Dental  Cosmos, 
Oct.,  1915). 

The  teeth,  as  end-organs,  are  the 
first  to  exhibit  a  diminution  in  im- 
munity to  infection,  if  any  form  of 
malnutrition  exists.  If,  by  exercise, 
massage,  and  other  hygienic  meas- 
ures, circulation  in  the  ultimate  capil- 
laries is  kept  moving,  the  gums  and 
peridental  tissue  will  frequently  re- 
tain their  immunity,  even  though 
malnutrition  be  present.  Pyorrhea 
alveolaris  is  a  result  of  malnutrition 
plus  infection,  and  also  most  fre- 
quently plus  irritation,  and  it  is 
greatly  intensified  if  arteriosclerosis 
of  the  ultimate  capillaries  sets  in. 
All  forms  must  commence  with  some 
form  of  gingivitis,  but  the  tissues 
vary  markedly  in  clinical  appearance. 

The  writer  is  inclined  to  recognize 
particular  types  of  pyorrhea  accord- 
ing to  the  associated  disease,  e.g.,  dia- 
betic pyorrhea,  tuberculous  pyorrhea, 
etc.  The  symptomatology  and  treat- 
ment difTer  in  each  type.  The  prog- 
nosis largely  depends  on  the  possibil- 
ity of  curing  the  malnutritional  fac- 
tor. Often  the  pyorrheal  changes 
will  appear  long  before  the  signs  of 
the  underlying  disease  are  sufficiently 
developed  to  permit  a  diagnosis. 
There  are  cases,  however,  in  which  a 
decrease  in  the  functional  power  of 
the  teeth  themselves  is  the  chief 
cause.  This  is  usually  due  to  such 
conditions  as  loss  of  one  or  more 
teeth,  irritation  from  unpolished  fill- 
ings, etc.  Often  when  the  underlying- 
constitutional  cause  is  found  it  will 
not  be   recognized  as   such,   but  will 


be  regarded  as  secondary  to  the  pyor-  may   initiate   pneumonia.      The   chronic 

rhea.      M.    L.    Rhein    (Jour.    Amer.  processes    of   the    series    are    benefited 

Med.  Assoc,  Feb.  10,  1917)).  ^^   autogenous   vaccines    in   most   in- 

Hartzell's  work   points   strongly   to  ^^^^^^^^^      j^   ^^^^^^  ^^^^^  ^^   ^,^^   ^.^^^^^ 

the  importance  of  the  streptococcus  m  . 

pyorrhea,    indicating    that    approxi-  there  IS  apparently  no  pus.    This  seem- 

mately  three-fourths  of  the  bacterial  ing  absence  may  be  due  to  shallow  or 

content  of  the  pus  pockets  is  made  up  wide     open     pockets,     the     pus     being 

of  pyogenic  cocci  of  the  Streptococcus  cashed  away  by  the  oral  secretions  as 

7'fru/fl;;.y  and  staphylococcus  types,  and  ...           ■.   ■     r            j          •.             u     j 

.      .,       r      .1  rapidly  as  it  IS  lormed.  or  it  may  be  due 

the     remammg    one-tourth     ot     other  .                                           .       -^ 

organisms.        Personal      observations  to    an    inactive    phagocytosis,    or    both 

relative  to  the  occurrence  of  strepto-  (Merritt). 

cocci,  staphylococci,  and  pneumococci  TREATMENT. — One     important 

in  pyorrhea  would  place  streptococci  feature  in  this  connection  is  the  pres- 

in  the  first  rank  as  regards  frequency,  r    i.     j.                 i-      i      i       .li        i       j 

,     ,    ,          .          .1-1  ence    of    tartar,    particularly    the    hard 

staphylococci     next,     while     pneumo-  ^                     •' 

cocci  are  observed  in  only  a  small  variety  derived  from  blood-serum  and 
percentage  of  cases.  A.  W.  Lescohier  made  up  of  various  phosphates,  car- 
(Jour.  Amer.  Med.  Assoc,  Feb.  10,  bonates  and  often  dark  in  color.  This 
^^^'^-  is  a  calculus  which  forms  along  the 
PATHOLOGY. — The  inflamma-  edges  of  the  gums  and  peridental 
tory  process  starts  at  the  margin  of  membrane.  The  first  step  is  to  care- 
the  gum  and  soon  involves  the  dental  fully  rid  the  teeth  of  any  tartar  that 
periosteum  and  surrounding  alveolar  may  be  present,  and  the  gums  of 
wall.  The  latter  being  a  medullary  decayed  teeth,  badly  fitting  crowns 
space  in  the  maxilla,  a  morbid  process  and  fillings,  angular  projections  from 
similar  to  osteomyelitis  develops,  end-  the  latter,  etc.  In  a  word,  the  patient 
ing  in  necrosis.  The  endameba  buccalis  should  be  placed  in  the  hands  of  a 
can  not  infrequently  be  detected,  and  all  competent  dentist,  who  should  be 
the  more  common  pyogenic  bacteria  informed  of  the  end  in  view, 
may  occur  in  the  lesions.  The  pneu-  Introduction  of  an  accessory  medi- 
mococcus  is  also  found  in  most  cases,  cinal  treatment  of  pyorrhea  followed 
As  shown  by  Rosenow  and  Billings,  the  discovery  of  Barrett  and  that  an 
there  is  a  close  connection  between  actively  motile  Endameba  buccalis 
the  pneumococcus  and  the  streptococ-  occurred  in  pyorrhea  pus  pockets, 
cus,  some  strains  of  the  latter  taken  The  fact  that  dysentery,  due  to  an 
from  tonsillar  crypts  having  been  con-  endameba,  yielded  promptly  to  emetine 
verted  under  various  cultural  con-  hydrochloride  suggested  its  use,  a 
ditions  into  typical  pneumococci.  solution  of  J^  per  cent,  of  this  salt 
The  same  convertibility  occurs  in  the  being  injected  into  the  pockets.  In 
streptococci  of  pyorrhea.  Hence  the  several  instances  of  the  13  cases 
fact  that,  precisely  -as  in  the  case  with  treated  the  pus  disa]:)peared  in  24 
the  tonsils,  streptococci  in  pockets  of  hours  and  the  gums  assumed  a  health- 
pyorrhea  alveolaris  may  give  rise  to  ier  appearance  after  the  third  or  sec- 
rheumatic  joint  infections,  arthritis  ond  injection.  Bass  and  Johns  (New 
deformans,  endocarditis,  pericarditis,  Orleans  Med.  and  Surg.  Journal,  vol. 
exophthalmic  goiter,  goiter,  gastric  Ixvii,  p.  456,  1914)  then  tried  the 
ulcer,    etc.,    while    the    pneumococcus  drug   hypodermically,   giving   y^    grain 




(0.03  Gm.)  until  the  amebse  had  dis- 
appeared and  keeping  up  the  effects 
by  local  applications  of  2  or  3  minims 
(0.12  to  0.18  CO.)  of  the  fluidextract 
of  ipecac  to  the  gums  with  the  tooth- 
brush after  carefully  cleansing  the 
teeth.  These  agents  sometimes  seemed 
curative  in  mild  cases,  but  when  the 
morbid  process  was  severe  the  organ- 
ism was  observed  to  recur. 

Of  190  cases  examined  187  showed 
endamebffi.  Of  the  187,  78  have  been 
treated  for  pyorrhea.  Of  the  78 
treated,  none  lost  their  endamebse 
permanently.  The  condition  of  the 
gums  and  teeth  was  greatly  improved 
in  3  cases,  moderately  improved  in  9 
cases,  slightly  improved  in  22  cases, 
while  41  cases  remained  the  same; 
the  results  were  doubtful  in  2  cases 
and  1  case  became  worse.  Practically 
all  that  were  found  negative  for 
endamebjE  at  the  conclusion  of  the 
injections  were  found  positive  for 
endamicbae  from  two  weeks  to  four 
months  later,  in  spite  of  using  a 
solution  of  ipecac  as  a  mouth-wash. 

Emetine  is  an  amebicide,  but  alone 
will  not  cure  pyorrhea  alveolaris.  J. 
S.  Ruofif  (U.  S.  Public  Health  Report, 
Reprint,  320,  1916). 

Suspecting  that  pyorrhea  is  due  to 
certain  spirochetes.  Kritchevsky  and 
Seguin  have  used  neoarsphenamine. 
Good  results  in  60  cases  reported 
from  mercury  succinimide  injections. 
In  the  pyorrheal  secretions  numbers 
of  large  spirochetes  were  observed 
which  generally  disappeared  almost 
completely  as  a  result  of  the  injec- 
tions. Among  244  cases  the  spiro- 
chetes were  found  in  large  number  in 
three-fourths  of  all  instances.  In 
healthy  mouths,  they  were  usually 
absent  or  few.  Six  to  10  injections  of 
0.1  to  0.6  Gm.  of  neoarsphenamine 
among  42  patients  all  showing  numer- 
ous spirochetes  caused  disappearance 
of  the  latter  in  29  cases,  in  the  ab- 
sence of  all  local  treatment.  Clinical 
improvement  was  marked.  The  treat- 
ment recommended  for  pyorrhea  is  as 

follows:  Intravenous  injection  of  0.1 
to  0.3  Gm.  of  neoarsphenamine.  If 
contraindications  or  special  technical 
difficulties  exist,  intramuscular  injec- 
tions of  mercury  succinimide.  Where 
the  tooth  is  entirely  loosened  and  the 
alveolar  process  destroyed,  the  tooth 
had  best  be  removed.  If  the  process 
is  but  partly  involved  the  roots 
should  be  scraped  and  even  carefully 
polished.  Fluorine  salts  assist  in 
breaking  up  the  tartar.  Neoarsphena- 
mine should  also  be  introduced  in  the 
pyorrheal  pockets  in  solution  or 
powder  form.  Recurrence  is  obviated 
only  by  persistent,  careful  cleansing 
of  the  teeth.  B.  Kritchevsky  and  P. 
Seguin   (Presse  med..   May   13,   1918). 

Some  observers  have  reported  good 
results  from  the  use  of  a  stock  bacterin 
or  autogenous  vaccine. 

In  the  cases  studied  by  the  writers, 
streptococci  predominated,  but  were 
associated  in  some  instances,  either 
with  Staphylococcus  aureus,  S.  albus, 
or  with  S.  citreus.  In  2  cases  there 
.  was  found  an  association  of  the  strep- 
tococcus and  of  the  Bacillus  pHeuinojiice, 
once  with  the  Micrococcus  catarrhalis, 
and  twice  with  a  pneumococcus. 

A  sensitized  vaccine  against  the 
streptococcus,  staphylococcus,  pneu- 
mococcus, and  bacillus  of  Friedlander 
was  thereupon  prepared.  For  M. 
catarrhalis  a  Wright  vaccine  was 
made.  Vaccine  injections  were  then 
made.  After  2  injections,  when  the 
antibodies  began  to  take  hold,  a 
mechanical  and  dental  treatment — 
Younger's — was  begun.  After  from 
4  to  5  injections,  it  was  found  impos- 
sible, either  by  microscopic  examina- 
tion or  by  cultures,  to  discern  the 
presence  of  the  bacteria.  The  authors 
have  kept  in  touch  with  a  number  of 
cases  for  six  months  after  treatment. 
These  cases  have  shown  no  recur- 
rence. Bertrand  and  Valadier  (N.  Y. 
Med.  Jour.,  Jan.  10,  1914). 

A  stock  vaccine  may  be  used,  either 
sensitized  or  unsensitized,  or  an 
autogenous  vaccine  prepared  from 
the  pus  pockets  may  be  employed. 
If   the   autogenous   is   preferred,   care 



should  be  taken  to  select  an  experi- 
enced bacteriologist  for  its  prepara- 
tion. If  an  unsensitized  bacterin  is 
employed,  the  initial  dose  advised  is 
ISO  million  of  the  mixed  bacteria; 
250  to  750  million  may  be  given  as 
the  initial  dose  if  the  sensitized  cul- 
tures are  employed.  Subsequent 
doses  are  injected  at  intervals  of 
seven  to  ten  days,  gradually  increas- 
ing or  decreasing  according  to  indi- 
cations. If  the  reactions  are  too 
severe,  the  doses  should  be  reduced 
or  temporarily  discontinued.  Every 
dose  should  be  carefully  gauged  by 
the  effect  obtained  from  the  preced 
ing  dose.  If  no  improvement  follows 
the  initial  dose,  subsequent  injections 
should  be  increased  until  amounts 
large  enough  to  produce  a  mild  clin- 
ical reaction  (demonstrated  by  symp- 
toms of  malaise  and  possibly  aggra- 
vation of  the  local  symptoms)  are 
reached.  If  a  marked  clinical  reac- 
tion occurs  after  a  dose,  characterized 
by  rising  temperature,  the  next  dose 
should  be  smaller.  F.  E.  Stewart  (N. 
Y.  Med.  Jour.,  Aug.  7,  1915). 

Injections  of  succinimide  of  mer- 
cury (1  grain — 0.065  Gm.)  weekly  are 
announced  as  curative  by  Wright  and 
White  (U.  S.  Navy),  from  one  to  six 
doses  having  been  sufficient  in  their 
cases  besides  the  local  measures. 
Copeland  (Dental  Cosmos,  Feb., 
1916)  confirms  these  observations. 
He  usd  a  B.  W.  8z  Co.  glass  syringe 
holding  40  minims  (2.5  c.c.)  and  a 
No.  26  intramuscular  needle,  the 
solution  being  %  grain  (0.013  Gm.) 
of  mercuric  succinimide  to  4  minims 
(0.25  c.c.)  of  hot,  sterile  distilled 
water.  The  injections  are  made  into 
the  buttock  after  sterilization  of  the 

The  writer  advocates  surgical  meas- 
ures, removing  the  diseased  tissues 
under  novocaine  anesthesia,  then  pack- 
ing with  iodoform  gauze  to  promote 
drainage  and  granulation.  The  pa- 
tient is  shown  how  to  flush  his  teeth 

with  warm  saline  solution  after  eat- 
ing for  the  post-operative  week.  This 
operation  does  not  cure  pyorrhea;  it 
is  the  only  method  which  prevents 
secondary  infection.  Nodine  (Dental 
Cosmos,  Ixiii,  345,   1921). 

The  writer  resorts  to  gingivoec- 
tomy,  cutting  away  under  local  anes- 
thesia all  loose,  infected  and  diseased 
tissues  to  eradicate  peridental  infec- 
tion. He  claims  to  have  obtained  a 
cure  in  90  per  cent,  of  his  cases. 
Ziesel  (Dental  Cosmos,  Ixiii,  352, 

Time  will  probably  show  that  such 
active  surgical  procedures  are  un- 
necessary to  cure  pyorrhea. 

Prophylaxis  is  an  important  fea- 
ture :  scrupulous  cleanliness  of  the 
mouth  and  regular  visits  to  the  den- 
tist to  check  any  incipient  disorder  of 
the  teeth  or  gums. 

C.  E.  DE  M.  Sajous, 


RINGWORM.  See  Trichophy- 

tassium AND  Sodium  Tartrate. 


This  eruptive  disease  has  been  known 
in  the  valley  of  the  Bitter  Root  River 
in  Western  Montana  and  in  Idaho 
since  1873,  although  the  first  specific 
reference  to  it  in  literature  was  made 
in  1896  by  the  Surgeon  General  of  the 
Army  in  his  annual  report.  The  dis- 
ease has  since  been  reported  from 
nearly  all  the  States  in  the  Rocky 
Mountain  group,  California,  Colorado, 
Idaho,  Montana,  Nevada,  Oregon, 
Utah,  Washington  and  Wyoming. 
Cases  have  also  been  reported  from 
the  District  of  Alaska.  The  disease  is 
especially  interesting  on  account  of 
its  geographical  limitation,  seasonal 
prevalence,  intimate  association  with 



wood  ticks,  and  variation  in  severity 
in  different  localities.  It  is  api)arently 
confined  to  the  American  Continent, 
being-  found  only  between  40°  and  47° 
north,  and  at  an  average  elevation  of 
between  3000  and  4000  feet  above 
sea  level.  It  prevails  exclusively  in 
the  spring  and  early  summer;  in  the 
Bitter  Root  cases  the  earliest  was 
March  17  and  the  latest  July  17. 
Those  whose  duties  take  them  into 
the  brush  and  expose  them  to  the  bite 
of  ticks  are  subject  to  the  disease, 
especially  stockmen,  sheep  herders, 
miners,  prospectors,  lumbermen  and 
ranchmen.  The  greatest  morbidity  is 
in  persons  between  15  and  50  years  of 
age,  presumably  because  they  are 
most  actively  engaged  in  outdoor 
work,  and,  for  the  same  reason,  males 
most  often  fall  victims  to  this  disease. 
It  is  not  contagious ;  2  cases  of  the 
disease  have  never  been  observed  in 
the  same  family  the  same  season. 

SYMPTOMS.— Incubation.— There 
is  a  stage  of  incubation  lasting  from 
three  to  ten  days,  usually  about  seven. 
For  a  few  days  the  patient  complains 
of  chilly  sensations,  malaise,  and  nau- 
sea, then  has  a  distinct  chill  and  takes 
to  his  bed.  Soon  there  are  pains  in 
the  back  and  head,  and  a  feeling  of 
soreness  in  the  muscles  and  bones, 
with  a  sensation  as  if  the  limbs  were 
in  a  vice.  The  bowels  are  constipated 
and  the  tongue  is  covered  with  a 
heavy  white  coat,  but  red  at  the  tip 
and  edges.  The  conjunctivae  are  con- 
gested, and  later  become  yellowish  in 
color.  The  urine  is  usually  scanty 
and  contains  albumin  and  casts. 
Epistaxis,  at  times  alarming,  is 
always  present,  and  slight  bronchitis 
appears  after  a  few  days. 

Fever. — Before  the  distinct  chill 
there  is  a  slight  rise  of  temperature 

in  the  afternoon,  l)ut  little  or  no  fever 
in  the  morning.  After  the  chill  there 
is  an  abrupt  rise,  with  a  gradual 
increase  of  the  fever  in  the  evening, 
and  a  slight  morning  remission,  the 
maximum  being  usually  reached  be- 
tween the  eighth  and  twelfth  days. 
In  a  favorable  case  it  then  gradually 
falls,  reaching  normal  about  the  four- 
teenth to  the  eighteenth  day,  usually 
going  to  subnormal  for  a  few  days. 
In  fatal  cases  the  fever  remains  higli 
(104°  to  106°  F.— 40°  to  41.1°  C.;, 
and  the  morning  remissions  are  either 
absent  or  very  slight.  Yet  the  tem- 
perature may  rise  to  105°  or  106"  F. 
(40.6°  to  41.1°  C.)  by  the  seventh  or 
eighth  day,  ending  in  favorable  cases 
by  lysis  on  tlie  ninth  or  tenth  day. 

Circulation. — The  pulse  is  acceler- 
ated out  of  all  proportion  to  the 
temperature,  a  pulse  of  120  being 
common  with  a  temperature  of  only 
102°  F.  (38.8°  C.)  ;  the  pulse  usually 
varies  from  110  to  140;  it  is  weak  and 
thready ;  a  full,  strong  pulse  is  excep- 
tional ;  during  the  first  week  it  may 
be  dicrotic.  There  is  a  progressive 
diminution  in  the  number  of  red 
blood-cells,  but  when  the  temperature 
reaches  normal  an  increase  begins. 

The  white  blood-corpuscles  are 
increased  in  number  varying  from 
8,000  to  12,000;  an  average  differen- 
tial count  would  give  :  polymorphonu- 
clear leucocytes,  77 .7  per  cent. ;  large 
mononuclears,  11.4  per  cent.;  small 
lymphocytes,  10  per  cent. ;  eosino- 
philes,  0.9  per  cent. ;  the  most  marked 
feature  being  an  increase  in  the  large 
mononuclears.  The  hemoglobin  is 
steadily  but  slowly  decreased — it  may 
go  as  low  as  50  per  cent.  The  blood 
will  not  agglutinize  Bacillus  typhosus; 
fresh  and  stained  blood  contains  three 
forms  of  the  pathogenic  parasite. 



A  sudden  rise  in  the  leucocyte 
count  is  an  unfavorable  sign. 

Eruption. — On  the  third  day  the 
eruption  usually  appears,  first  on 
the  wrists  and  ankles,  then  on  the 
arms,  legs,  forehead,  back,  chest,  and, 
last  and  least,  on  the  abdomen. 
Although  the  other  portions  of  the 
body  may  be  closely  covered  by  the 
eruption,  it  is  always  scanty  on  the 

The  spots  are  at  first  bright-red, 
always  macular,  and  in  size  from  a 
pinpoint  to  a  split  pea,  at  first  dis- 
appear on  pressure  and  return  quickly ; 
in  severe  cases  they  rapidly  become 
darker,  even  purplish  in  color.  From 
the  sixth  to  the  tenth  days  of  the 
disease,  the  spots  do  not  disappear  on 
pressure  and  are  decidedly  petechial 
in  character.  In  favorable  cases, 
about  the  fourteenth  day  they  lose 
their  petechial  character  and  disap- 
pear slowly  on  pressure.  The  erup- 
tion may  assume  the  appearance  of  a 
turkey-egg,  the  skin  being  flecked 
with  small,  brownish  spots.  The  erup- 
tion fades  as  the  fever  declines,  but 
an  access  of  fever,  a  warm  bath,  or  a 
free  perspiration  will  bring  it  out  dis- 
tinctly. Desquamation  begins  when 
convalescence  is  well  advanced  and 
is  general.  In  very  severe  cases  there 
may  be  gangrene  of  the  fingers,  toes, 
and  more  frequently  of  the  skin  of  the 
scrotum  and  penis.  Jaundice  is 
always  present,  first  in  the  conjunc- 
tivae and  later  involving  the  entire 
cutaneous  surface. 

The  Gastrointestinal  Tract. — The 
tongue  is  covered  at  first  with  a 
heavy,  whitish  coat,  except  on  the 
edges  and  tip,  which  are  red ;  later  the 
coating  is  dark  brown  and  sordes 
covers  the  teeth.  The  appetite  is  often 
good     throughout     the     first     week. 

although  there  may  be  slight  nausea. 
In  fatal  cases  the  nausea  increases 
during  the  second  week  and  persists. 
Constipation  is  always  present  and 
continuous.  Gurgling  is  seldom  found 
m  the  right  iliac  fossa  and  tympanites 
is  never  excessive.  Moderate  increase 
in  the  size  of  the  liver  is  present,  and 
the  spleen  is  enlarged  early  and  may 
extend  one  or  two  inches  below  the 
ribs.     Black  vomit  is  common. 

The  Urinary  Tract. — The  urinary 
output  is  one-half  the  normal.  Albu- 
min in  small  amount  is  present  in  all 
cases,  associated  with  granular,  hya- 
line, and  epithelial  casts.  Nephritis 
may  appear  early  in  the  history  of 
the  case. 

The  Respiratory  Tract. — The  res- 
pirations are  always  accelerated,  be- 
ing usually  from  26  to  40  per  minute, 
although  they  may  reach  50  to  60; 
they  are  regular  but  often  shallow. 
Slight  bronchitis  always  appears  in 
the  second  week.  In  fatal  cases  lobar 
pneumonia  is  a  frequent  complication. 
Epistaxis  is  generally  observed  from 
the  beginning  of  the  second  week. 

Nervous  System. — Headache  and 
pains  in  the  back  are  usually  severe 
during  the  first  week.  A  feeling  of 
soreness  in  the  muscles  and  bones, 
often  very  severe,  even  in  mild 
cases,  is  present  and  persists  until 
recovery.  The  mind  is  usually  clear, 
in  severe  cases,  until  a  few  hours 
before  death. 

DIAGNOSIS. — Diagnosis  Is  usually 
easy  in  cases  occurring  in  infected 
localities,  which  present  a  history  of 
tick-bites  and  the  typical  symptoms  of 
this  disease;  a  blood  examination  will 
clear  up  any  doubtful  case.  There 
are,  however,  five  diseases  to  which 
it  bears  more  or  less  close  resem- 
blance from  which  this  disease  must 



be  differentiated:  deni^ue,  cerebro- 
spinal menins^itis,  pcliosis  rhcumatica, 
typhoid  and  ty])hus  fevers. 

Dengue  is  a  disease  of  tropical  and 
subtropical  countries,  while  spotted 
fever  is  found  at  elevations  of  from 
3000  to  4000  feet  above  sea-level 
The  swollen  joints,  polymorphic  erup- 
tion (never  petechial)  over  the  joints, 
apyretic  period,  and  short  duration  of 
dengue  would  distinguish  it. 

Cerebrospinal  meninyitis  is  marked 
by  the  characteristic  stiffness  of  the 
neck  muscles,  photophobia,  extreme 
sensitiveness  to  sudden  noises,  head- 
ache, rigidity  of  the  muscles  of  the 
back  and  neck,  and  a  rash  which  is 
not  only  irregular  in  location,  but  also 
in  appearance. 

Peliosis  rhemnatica  is  a  compara- 
tively rare  disease  in  which  there  is 
a  characteristic  sore  throat  associated 
with  multiple  arthritis,  purpura,  and 

Typhoid  fever  clinically  closely 
resembles  spotted  fever  except  in  the 
rose-colored  spots  (papular)  which 
appear  first  on  the  abdomen,  the  diar- 
rhea, the  Widal  reaction,  the  presence 
of  typhoid  bacilli  in  blood-cultures, 
and  the  absence  of  the  parasites 
formed  in  the  red  blood-cells  of  spot- 
ted fever. 

Typhus  fever  so  closely  resembles 
spotted  fever  that  cases  of  typhus 
fever  occurring  in  a  spotted-fever  dis- 
trict, without  a  blood  examination  and 
close  clinical  observation,  might  easily 
be  counfounded  with  it.  In  typhus 
fever,  however,  we  have  a  larger  incu- 
bation, absence  of  tick-bites,  the  erup- 
tion which  appears  first  on  the  abdo- 
men and  chest,  and  an  intensely  con- 
tagious character.  Typhus  is,  more- 
over, especially  prevalent  during  the 
winter   months,   and    not    during  the 

late  spring  and  early  summer,  and  is 
accompanied  by  marked  nervous 

ETIOLOGY.— Spotted  fever  is 
caused  by  a  protozoan  parasite  which 
is  transmitted  to  man  thrrjugh  the 
bite  of  the  wood  tick  (Dermacentor 
andersoni).  To  Wilson  and  Chowning 
belongs  the  credit  of  discovering  this 
parasite,  three  forms  of  which  have 
been  identified  by  John  F.  Anderson, 
the  most  common  is  a  single  ovoid 
body,  refractile,  situated  within  the 
red  blood-cell,  usually  near  its  edge, 
and  closely  resembling  the  earliest 
intracorpuscular  parasites  of  estivo- 
autumnal  malaria.  When  the  blood 
upon  the  freshly  prepared  slide  is 
warmed  the  parasite  quite  rapidly 
projects  pseudopodia  and  may  change 
its  position  slightly.  A  second  form, 
somewhat  rarer,  is  larger,  and  larger 
at  one  end  and  showing  there  a  dark, 
granular  spot;  this  form  is  also  ame- 
boid. The  third  form,  arranged  in 
pairs,  is  pyriform  in  shape,  with  the 
smaller  end  approaching,  and  in  some 
cases  being  united  by  a  fine  thread. 
The  parasite  is  developed  in  the 
female  tick  and  the  young  ticks,  after 
being  hatched,  transmit  the  infection. 
The  female  gets  her  infection  by  bit- 
ing one  convalescent  from  spotted 

Three  types  of  the  spotted  fever 
parasite  can  be  recognized:  (1)  An 
extranuclear  bacilius-Hke  form  with- 
out chromatoid  granules,  relatively 
large  and  only  present  in  ticks  dur- 
ing the  initial  multiplication  of  the 
parasites;  (2)  a  relatively  small  rod- 
shaped  form  with  chromatoid  gran- 
ules, probably  the  same  form  seen 
within  nuclei  in  sections  of  ticks,  and 
rarely  in  smooth  muscle  cells  in  the 
blood-vessel  of  mammals;  and  (3)  a 
relatively  large  lanceolate  paired  form 
present  in  ticks  and  in  the  blood  and 



lesions  in  mammals.  The  name  Der- 
macentroxcmis  rickcttsi  is  proposed. 
S.  B.  Wolbach  (Jour.  Med.  Re- 
search,   Nov.,    1919). 

PROGNOSIS.  — The  mortality 
varies  between  70  and  90  per  cent. 
Death  usually  occurs  between  the 
sixth  and  the  twelfth  day.  There  is 
no  relation  between  abundance  of  the 
eruption  and  severity  of  the  disease. 

TREATMENT. — Quinine   bimuri- 

ate  in  15-grain  (1  Gm.)  doses  every 
six  hours,  preferably  hypodermically, 
has  yielded  excellent  results  in  the 
hands  of  Wilson  and  Anderson.  Qui- 
nine sulphate,  15  grains  (1  Gm.),  may 
be  given  by  mouth  every  four  hours, 
and  should  be  begun  as  soon  as  the 
■diagnosis  is  made,  and  persisted  with 
in  decreasing  doses  as  convalescence 
begins.  The  heart  should  be  sup- 
ported with  strychnine,  whisky  (egg- 
nog),  or  other  cardiac   stimulants. 

The  severe  pain  in  the  head  and 
back,  during  the  first  week,  may  be 
relieved  by  the  use  of  Dover's  powder 
or  morphine  sulphate.  It  is  well  to 
flush  the  kidneys  through  the  use  of 
copious  draughts  of  water.  Warm 
sponge  baths  or  packs  are  useful  in 
controlling  the  fever.  The  room 
should  be  darkened  and  free  from 
noise.  In  the  way  of  diet  milk,  butter- 
milk, broths,  soft-boiled  eggs,  and 
moistened  toast  may  be  given. 

In  the  way  of  prophylaxis,  Ander- 
son advises  that  as  soon  as  a  person 
is  bitten  by  a  tick  the  insect  should 
be  removed  and  95  per  cent,  carbolic 
acid  applied  to  the  spot.  If  there  is 
difficulty  in  removing  the  tick,  Ander- 
son suggests  the  application  of 
ammonia,  turpentine,  kerosene,  or  car- 
bolized  petroleum  to  it. 

The   treatment  is   rather   unsatisfac- 
tory,    being    mainly     supportive     and 

symptomatic;  the  only  drug  of  much 
service  is  sodium  citrate  given  in- 
travenously to  the  limit  of  tolerance 
from  the  start.  Sixty  c.c.  of  a  5  per 
cent,  fresh  sterile  solution  may  be 
given  intravenously  twice  daily.  H. 
C.  Michie  and  H.  H.  Parsons  (Med. 
Rec,    Feb.    12,    1916). 

C.  Sumner  Witherstine, 


RUBELLA,  Rotheln,    German 


DEFINITION.  — Rubella  is  an 
acute,  infectious,  contagious  disease 
of  mild  character,  presenting  some- 
what variable  symptoms  and  running 
a  favorable  course.  Its  identity  as  a 
disease,  siii  generis,  was  long  doubted. 
There  is  now  no  question,  however, 
that  it  is  a  distinct  entity  among  dis- 
eases, though  it  strongly  resembles 
in  its  different  manifestations  measles 
and  scarlet  fever.  No  better  state- 
ment of  present  beliefs  regarding  its 
true  character  has  been  made  than 
that  of  Griffith,  which  is  as  follows : 
"(1)  rubella  is  a  contagious,  eruptive 
fever,  and  not  a  simple  affection  of 
the  skin;  (2)  it  prevails  independently 
either  of  measles  or  of  scarlet  fever; 
(3)  its  incubation,  eruption,  invasion, 
and  symptoms  diff'er  materially  from 
both  of  these  diseases ;  (4)  it  attacks 
indiscriminately  and  with  equal  sever- 
ity those  who  have  had  measles  and 
scarlet  fever  and  those  who  have  not, 
nor  does  it  protect  in  any  degree 
against  either  of  them;  (5)  it  never 
produces  anything  but  rubella  in 
those  exposed  to  its  contagion  ;  (6)  it 
occurs  l)Ut  once  in  the  indi\'idual." 

This  period  is,  according  to  Holt,  8 
to  16  days,  the  limits  being  5  to  22 
days ;  Rotch,  21  days ;  Edwards,  7  to 
14  days ;  Plant,  1  to  3  weeks ;  Smith, 
about  2  weeks.    These  figures  clearly 



show  that  the  period  of  incubation  is 
of  considerable  length  and  extremely 
variable.  The  indefiniteness  arises 
not  so  much  from  lack  of  observation 
as  from  variability  in  the  disease.  To 
say  that  the  period  of  incubation  is 
about  two  weeks  is  probably  as  cor- 
rect and  definite  a  statement  as  can 
be  made. 

SYMPTOMS.— The  symptoms  of 
rubella  are  extremely  variable,  so 
much  so  in  fact  that  we  must  agree 
with  Rotch  that  it  is  impossible  to  de- 
scribe a  typical  case  in  such  a  way 
that  the  disease  can  be  certainly  di- 
agnosticated in  a  sporadic  case. 
Many  cases,  however,  run  a  fairly 
consistent  and  characteristic  course. 
The  invasion  is  seldom  severe.  In 
some  cases  there  is  a  prodromal  stage 
lasting  a  few  hours ;  in  others  the 
rash  is  the  first  svmptom  to  be  ob- 
served. The  fever  is  rarely  high  and 
often  does  not  rise  above  100°  F. 
(37.8°  C),  but  commonly,  when  at  its 
height,  on  the  first  day  of  the  erup- 
tion, it  reaches  101°  or  102°  F.  (38.3° 
or  38.9°  C).  It  occasionally  rises  to 
104°  F.  (40°  C.)  or  more.  The 
drowsiness,  stupor,  and  other  evi- 
dences of  serious  illness  so  frequently 
seen  at  the  height  of  measles  are 
rarely,  if  ever,  seen  in  rubella.  A 
child  with  a  bright  and  very  exten- 
sive eruption  will  frequently  show  no 
sign  of  general  illness. 

In  my  own  experience  sore  throat 
has  been  the  rule.  The  tonsils  and 
pharynx  are  red  and  swelled  and  there 
is  pain  on  swallowing.  This  is  oc- 
casionally so  marked  as  to  be  sug- 
gestive of  scarlet  fever;  the  vomiting 
so  common  at  the  outset  of  that  dis- 
ease, however,  is  rarely  present.  A 
secondary  sore  throat  which  comes  on 
as  the  disease  is  subsiding  was  first 

noted  by  Eustace  Smith  as  very  char- 
acteristic of  rubella.  It  certainly  oc- 
curs in  some  cases.  Koplik's  spots 
do  not  ai)pear.  The  symptoms  of  the 
]M-imary  angina  subside  on  the  second 
or  third  day  and  rapidly  disappear. 
There  are  no  catarrhal  symptoms  in 
most  cases,  but  occasionally  slight 
suffusion  of  the  eyes  and  a  mild  ca- 
tarrh will  render  the  diagnosis  from 
measles  more  difficult.  Albuminuria 
is  rarely  if  ever  present,  and  the  diazo- 
reaction  is  extremely  rare.  Moderate 
leucocytosis  occurs  during  the  incu- 
bation period,  but  disappears  as  the 
eruption  fades. 

Hematological  diagnosis  of  ro- 
theln.  Three  cases  under  treatment 
appeared  clinically  as  measles,  but 
the  first  soon  proved  itself  rotheln. 
Two  weeks  later  two  similar  cases 
were  admitted.  The  writer  then  com- 
pared the  blood-counts  of  the  cases 
with  examples  of  true  measles.  He 
found  that  in  rotheln  at  the  high 
point  of  the  disease  there  was  none 
of  the  disappearance  of  eosinophiles 
which  characterizes  measles;  nor  was 
there  the  leucopenia  regarded  as 
normal  in  the  latter  disease.  Schwaer 
(Mitnch  med.  Woch.,  May  27,  1913). 

Enlargement  of  the  postcervical 
and  suboccipital  glands  is  a  very  con- 
stant and  very  characteristic  symp- 
tom of  rubella.  Numerous  small 
glands  may  almost  invariably  be  felt 
behind  the  sternomastoid  well  down 
toward  the  shoulder;  they  rarely  be- 
come very  large  and  never  suppurate. 
They  may  be  felt  most  distinctly 
when  the  rash  is  at  its  height,  and 
disappear  rapidly.  While  they  aid 
materially  in  diagnosis,  and  may  per- 
haps be  called  diagnostic,  they  are 
certainly  not  pathognomonic,  for  they 
may  at  times  be  met  in  measles  and 
in  rare  cases  be  found  in  scrofulous 
children  without  febrile  symptoms. 



Most  salient  features  by  which  one  may  distinguish  rubella  from  measles 
and  scarlet  fever  are  as  follows,  as  given  by  N.  S.  Manning: — 



Scarlet  Fever. 



Three    to    five    days, 
with     pyrexia     and 
conjunctival        and 
bronchial  catarrh. 

Twelve  to  twenty- 
four  hours,  pyrexia, 
headache,  and 


Slight  or  absent. 

Marked  conjunctivitis, 
coryza,   cough,   etc. 



Appears  on    face   and 
chest       as       bright, 
pink-red        maculre, 
first  under  the  cuti- 
cle,   which    become 
raised,     with    tend- 
ency to   spread  and 

Appears    on    face    as 
darkish-red,    slight- 
ly   raised    papules ; 
extends      to      trunk 
and    limbs ;   papules 
become       confluent, 
but     distribution     is 

Appears  on  chest  as 
diffuse  general  red- 
ness of  skin. 

form      irregular 
patches    or    become 

more  uniform. 


Slight     swelling     and 
injection  of   fauces. 

Fauces    injected. 

All  the  faucial  struct- 
ures acutely  in- 
flamed, swelled  and 
red,  or  ulcerated. 




Thickly  furred,  which 
begins  to  strip  off 
in  twenty- four  or 
forty-eight       hours. 

Superficial        lymphatic 

Always     enlarged     in 
axillt-e,    groins,    and 
behind      stcrnomas- 
toid  muscle  in  neck. 

May    be    enlarged    at 
angles   of   jaw    and 
behind      sternomas- 
toid  muscle. 

leaving  raw  sur- 
face, with  enlarged 

May  be  enlarged  at 
angles  of  jaw  and 
behind  sternomas- 
toid  muscle. 


Absent  or  very  slight. 


Characteristic  peeling 
off  of  large  pieces 
of  epithelium. 

Forchheimer  describes  an  exan- 
them  which  is  seen  in  the  mouth  as 
the  exanthem  appears  on  the  body.  It 
usually  lasts  about  twenty-four  hours. 
"It  consists  of  a  macular,  distinctly 
rose-red  eruption,  upon  the  velum  of 
the  palate  and  the  uvula,  extending 
to  but  not  on  the  hard  palate.  The 
spots  are  arranged  irregularly,  not 
crescentically,  of  the  size  of  large 
pinheads,  very  little  elevated  above 
the  level  of  the  mucous  membrane, 
and  do  not  seem  to  produce  any  reac- 
tion tipon  it." 

The  eruption  appears  first  upon  tlie 

face  or  forehead  and  extends  rapidly 
over  the  neck,  trunk,  and  limbs.  The 
whole  body  is  usually  covered  within 
twenty-four  hours.  Occasionally  the 
child  will  wake  in  the  morning  with 
a  rash  covering  the  greater  portion  of 
the  body.  In  many  cases  the  rash  is 
limited  to  small  areas,  the  greater 
portion  of  the  body  escaping  entirely. 
It  is  more  constant  upon  the  face  than 
any  other  region.  In  some  cases  the 
rash  continues  not  more  than  twenty- 
four  hours,  but,  as  a  rule,  it  is  present 
from  two  to  four  days.  Itching  is 
common  at  the  outset. 



A  slight,  scaly  desquamation  may 
follow  the  disappearance  of  the  rash, 
but  in  many  cases  no  desquamation 
can  be  detected.  This  is  particularly 
true  when  inunction  of  the  body  has 
been  practised. 

The  eruption  consists  of  papules  or 
maculopapules  of  a  red  or  rose-red 
color.  They  vary  greatly  in  size, 
varying  from  a  pin's-head  point  to  a 
large  blotch.  Tliis  multiform  charac- 
ter is  one  of  the  peculiarities  of  the 
eruption  of  rubella.  IMost  of  the 
spots  are  smaller  than  those  of 
measles  and  larger  than  those  of  scar- 
let fever.  They  vary  in  size  on  differ- 
ent portions  of  the  body,  and  even  in 
the  same  region  the  rash  will  be 
found,  as  a  rule,  to  be  made  up  of 
small  dots  interspersed  with  larger 
and  irregular-shaped  spots  or  blotches. 
It  lacks  the  uniformity  of  the  rash 
seen  in  scarlet  fever  or  measles.  The 
rash  more  commonly  resembles  that 
of  measles  and  it  is  frequently  impos- 
sible to  make  a  diagnosis  from  it 
alone.  Edwards  has  recently  alleged 
that  he  has  not  seen  the  rash  resem- 
ble that  of  scarlet  fever.  That  is  not 
my  experience.  I  have  frequently 
seen  a  rash  consisting  of  small  points 
grouped  closely  upon  a  reddened 
skin  that  looked  extremely  like  scarlet 
fever.  Search  over  the  body,  in  such 
cases,  however,  will  usually  reveal 
small  areas  of  eruption  composed  of 
maculopapules,  appearing  as  large 
spots.  These  are  commonly  found 
upon  the  arms,  wrists,  or  hands.  I 
quite  agree  with  those  who  describe 
a  scarlatinal  and  rubeolar  type  of 
eruption.  I  have  seen  these  two  types 
well  marked  in  two  children  of  the 
same  family  exposed  at  the  same  time, 
and  ill  in  the  same  room.  The  rash 
of   one,   consisting   of   large   maculo- 

papules ver}'  strongly  resembled 
measles;  that  of  the  other,  consisting 
of  much  finer  points  on  a  reddened 
skin,  as  strongly  resembled  scarlet 

A  disease  was  described  by  Clem- 
ent Dukes,  of  England,  in  1900,  to 
which  he  gave  the  name  of  "Fourth 
Disease."  The  condition  which  is  de- 
scribed is  virtually  that  which  I  have 
here  described  as  the  scarlatinal  form 
of  German  measles.  The  differential 
diagnosis  given  by  Dukes  between 
German  measles  and  fourth  disease 
describes  a  condition  identical  except 
as  to  the  rash.  He  admits  that  in 
the  same  patient  the  eruption  some- 
times resembles  measles  and  may 
change  later  to  a  scarlatinal  type. 

The  subject  has  received  extended 
study  since  Dukes  promulgated  the 
theory  of  a  fourth  disease.  After  care- 
ful observation  of  1335  cases  seen  in 
the  London  Fever  Hospital,  Beards 
and  Goldie  did  not  see  any  they  felt 
thev  could  record  as  fourth  disease. 
AVatson  Williams  made  a  very  care- 
ful study  of  2)2  cases  of  rubella  and 
questions  the  existence  of  a  fourth 
disease.  Pleasants,  of  Baltimore,  also 
concludes  that  the  existence  of  a  new 
exanthematic  disease  has  not  been  es- 
tablished. After  an  extended  review 
of  the  whole  subject  Ker  concludes 
that  the  fourth  disease  is  either  mild 
scarlet  fever  or  atypical  rubella. 
From  study  of  the  literature  and  from 
considerable  experience  it  seems  to  me 
that  we  have  not  sufficient  evidence 
to  warrant  us  in  describing  a  fourth 

ETIOLOGY.— Analogy  leads  to 
the  belief  that  rubella  is  caused  by  a 
specific  micro-organism,  but  the  germ 
has  not  yet  been  discovered.  It  is 
contagious,  though  not  as  strongly  so 



as  scarlet  fever  and  measles.    Its  con- 
tagious power  at  times   seems  to  be 
very    slight.      It    is    most    contagious 
when  the  eruption  is  at  its  height.    It 
is    rarely,    if    ever,    seen    under    six 
months,  but  after  that  age  no  period 
of  life  is  exempt.     It  is  most  common 
between  5  and  10  years.     The  recur- 
rence  of   true    rubella    is    rare.      The 
disease  usually  occurs   in   epidemics, 
which  are  most  common  in  the  spring. 
QUELJE. — No  other   infectious   dis- 
ease  is    so    free    from    complications. 
This    is,    in    fact,    one    of    the    most 
marked  peculiarities  of  rubella.    Even 
varicella  sometimes  shows  a  serious 
complication  :     that  of  gangrene.     No 
such  serious  symptom  is  likely  to  arise 
in    rubella.      The    pneumonia,    otitis, 
erysipelas,     and     multiple    abscesses, 
which  in  rare  instances  have  been  re- 
ported as  accompanying  rubella,  are 
perhaps  not  in  every  case  a  complica- 
tion, but  rather  a  coincidence. 

The  writer  reports  the  following 
unusual  case:  The  patient,  a  male,  de- 
veloped, after  a  few  days  of  sore 
throat,  stifi  neck,  malaise,  and  moder- 
ate fever,  a  rash  having  the  distribu- 
tion and  appearance  of  German  meas- 
les and  accompanied  by  an  enlarge- 
ment of  superficial  glands,  notably 
those  of  the  neck.  Before  the  exan- 
them  had  faded  the  patient  began  to 
complain  of  stiffness  and  tenderness 
in  the  knees  and  ankles,  and  soon 
all  the  interphalangeal  joints  of  the 
fingers  presented  the  spindle-like 
swelling  commonly  seen  in  rheuma- 
toid arthritis.  There  was  no  exacer- 
bation of  temperature  and  neither 
cardiac  nor  other  complication.  A 
fortnight  from  the  appearance  of  the 
rash  all  the  symptoms  were  subsiding, 
and  in  the  six  months  there  was  only 
an  occasional  transient  stififness  in 
the  fingers.  D.  A.  Alexander  (Lan- 
cet, ii,  p.  921,  1907). 

In  an  epidemic  in  an  institution 
for  children,  out  of  80  cases  2 
children  developed  chickenpox  before 
recovering  from  rubella,  1  developed 
rubella  before  recovering  from  chic- 
kenpox, and  1  child  had  a  severe 
ulcerative  stomatitis.  May  Michael 
(Arch,  of  Pediat.,  Aug.,  1908). 

PROGNOSIS.  — Death  from  ru- 
bella is  extremely  infrequent.  In  rare 
cases  in  which  it  occurs  it  is  usually 
the  result  of  some  pulmonary  disease, 
occurring  either  as  a  complication  or 
as  a  coincidence. 

TREATMENT.— Rubella  requires 
very  little,  if  any,  treatment.  Mild 
treatment  appropriate  to  any  febrile 
condition  is  permissible,  but  if  the 
patient  is  kept  in  bed  while  the  fever 
and  rash  continue,  and  is  anointed 
daily  with  oil,  further  treatment  will 
rarely  be  required.  Symptoms  must 
be  treated  as  they  arise.  In  most 
cases  the  disease  as  such  is  of  but  lit- 
tle importance,  its  chief  interest  lying 
in  its  diagnosis,  owing  to  its  resem- 
blance to  two  more  serious  diseases. 

Floyd  M.  Crandall, 

New  York. 

RUBEOLA.     See  Measles. 

RUE.— Rue  (Ruta)  is  the  leaves  of 
Riita  gravcolens  (fam.  Rutaceas),  a  peren- 
nial herb  or  undershrub  of  Southern  Eu- 
rope, but  cultivated  elsewhere  as  a  domes- 
tic medicinal  herb.  The  important  con- 
stituent (0.06  per  cent.)  of  rue  is  a  volatile 
oil,  colorless  or  slightly  yellow  and  of  low 
specific  gravity,  and  extremely  unpleasant 
and  odorous.  It  was  official  in  the  U.  S. 
r.  from  1870  to  1890.  Rue  also  contains 
a  glucoside  (rutin-rutic  or  rutinic  acid) 
which  is  yellow  and  crystalline  and  ap- 
parently identical  with  the  barosmin  of 
buchu,  considerable  sugar,  and  possibly  a 
volatile   alkaloid. 

Oleum  mice  (oil  of  rue).  Dose,  3  to  6 
minims    (0.20  to  0.40  c.c),  in  capsule. 

Ruta   (rue).     Dose,  15  to  30  grains   (1  to 



2  Gm.),  usually  in  infusion.  Neither 
preparation    is    now    official. 

a  local  irritant  and  vesicant.  Internally 
it  is  a  stimulant,  carminative  and  em- 
menagogue.  In  large  doses  it  is  an 
irritant  poison,  producing  severe  gastro- 
enteritis, vomiting,  abdominal  pain  and 
meteorism,  bloody  stools,  suppression  of 
urine,  or  stranguary,  and  epileptiform  con- 
vulsions. Dimness  of  vision  with  con- 
tracted pupils  are  observed.  Abortion  may 
result  from  toxic  doses.  It  has  some  spe- 
cial action  upon  the  genitourinary  tract, 
and  is  eliminated  in  the  breath,  the  urine, 
and  in  the  perspiration.     It  is  rarely  fatal, 

THERAPEUTIC  USES.— In  medicinal 
doses  it  is  given  as  a  uterine  stimulant  in 

atonic  amenorrhea,  menorrhagia,  and  me- 
trorrhagia. Its  employment  as  an  aborti- 
facieiit  entails  great  danger  to  the  mother. 
Hysteria,  especially  when  associated  with 
amenorrhea,  is  benefited  by  the  drug.  It 
has  also  been  friund  xiscful  in  flatulence 
and  infantile  convulsions.  In  defective 
activity  of  the  sexual  organs,  it  acts  as 
an  aphrodisiac  and  emmenagogue.  The 
bruised  leaves  of  rue  laid  upon  the  fore- 
head has  been  used  by  Phillips  to  check 
epistaxis.  Added  to  liniments  rue  has 
found  favor  as  an  application  to  the 
chest  in  chronic  bronchitis.  A  decoction 
of  the  fresh  leaves  may  be  used  as 
an  injection  against  seatvirorms  (oxyuris) 
and  has  often  been  given  internally  to 
expel  roundworms  (ascarides).  W. 

SACCHARIN.  —Saccharin  (benzo- 
sulphiiiidum,  U.  S.  P.;  glusidum,  Br.; 
neosaccharin;  gluside;  benzoyl  sulphonic- 
imide),  or  the  anhydride  of  orthosulpha- 
mide- — benzoic  acid  (C7H5NO3S),  is  a  coal- 
tar  derivative  obtained  commercially  from 
toluene  discovered  by  C.  Fahlberg  in  1879. 
Saccharin  occurs  as  a  white,  crystalline 
powder,  nearly  odorless,  having  an  in- 
tensely sweet  taste  even  in  dilute  solu- 
tions. Iti  is  soluble  in  250  parts  of  water 
and  in  25  parts  of  alcohol,  and  but  slightly 
soluble  in  ether  and  chloroform.  It  read- 
ily dissolves  in  24  parts  of  boiling  water. 
Saccharin  dissolves  also  in  glycerin.  Its 
solubility  in  water  is  promoted  by  the  ad- 
dition of  sodium  bicarbonate  in  the  pro- 
portion of  2  parts  to  3  of  saccharin. 
Saccharin  forms  soluble  salts  with  the  hy- 
drates of  the  alkaline  metals.  It  melts  at 
220°  C.  (428°  F.),  and  when  fused  with 
potassium  or  sodium  hydroxide  it  forms 
salicylic  acid.  It  is  300  times  sweeter  than 

Sodium  saccharin,  also  known  as  soluble 
saccharin,  soluble  gluside,  and  crystallose, 
is  prepared  by  neutralizing  an  aqueous 
solution  of  saccharin  with  sodium  car- 
bonate or  bicarbonate  and  slowly  crys- 
tallizing the  solution.  It  occurs  in  color- 
less crystals,  very  soluble  in  water,  in- 
tensely  sweet   to   the   taste,   and    not   dis- 

colored by  concentrated  sulphuric  acid. 
It  is  a  favorite  substitute  for  saccharin  be- 
cause of  its  greater  solubility. 

Saccharin  when  present  in  food  products 
or  mixtures  may  be  separated  by  extract- 
ing the  saccharin  from  an  acidulated 
solution  of  the  substance  with  ether,  sep- 
arating the  ether  and  then  evaporating  the 
ethereal  solution  thus  obtained.  The  aver- 
age dose  of  saccharin  is  3  grains  (0.2  Gm.). 

charin apparently  is  not  decomposed  in 
the  body,  as  it  is  excreted  by  the  kidneys 
imchanged;  the  urine,  however,  does  not 
so  readily  undergo  fermentation  and  the 
chlorides  are  increased.  Mathews  and 
McGuigan,  in  studying  the  effects  of  sac- 
charin on  oxidation  and  digestion,  report 
that  it  has  a  marked  retarding  action  on 
oxidation  in  the  blood  and  muscles,  and 
also  on  the  action  of  the  digestive  juices, 
especially  those  of  the  salivary  glands 
and  pancreas.  Its  prolonged  use  is  likely 
to  cause  digestive  disorders.  When  in- 
jected into  the  circulation  of  an  animal,  it 
produces  depression  and  stupor,  followed 
by  labored  respiration,  similar  to  asphyxia. 
The  writers  attribute  these  effects  to  its 
inhibitory  action  on  the  enzymes  of  the 
blood  and  tissues,  which  also  explains  the 
headaches  and  other  symptoms  its  use 
often  gives  rise  to.     It  is  believed  to  be  a 


general  protoplasmic  poison  in  that  it  in- 
hibits fiearly  all  the  fermentative  processes 
of  the  body,  and  interferes  with  and 
diminishes  general  bodily  metabolism. 
Saccharin  has  antiseptic  properties  which, 
however,  are  impaired  in  the  presence  of 
an  acid  medium. 

Large  doses  of  saccharin  are  capable  of 
producing  marked  toxic  symptoms,  as  in 
a  case  reported  by  Luth,  where  a  woman 
having  swallowed  about  30  grains  (2  Gm.) 
of  saccharin  was  found  in  a  state  resem- 
bling that  of  alcoholic  intoxication.  She 
was  unconscious  and  foamed  at  the  mouth. 
Her  face  was  flushed  and  she  suffered 
from  convulsive  attacks,  with  choking. 
The  respirations  were  rapid  and  the  pulse 
weak,  very  rapid,  intermittent,  and  irregu- 
lar.    Poisoning  by  saccharin  is  rather  rare. 

the  foregoing,  under  artificial  respiration 
and  massage  of  the  heart,  the  pulse  within 
half  an  hour  became  stronger  and  regular, 
and  the  respiration  became  normal.  After 
forty-five  minutes  the  patient  awoke  and 
felt  quite  well. 

THERAPEUTIC  USES.  — Saccharin  is 
chiefly  used  as  a  sul)stitute  for  sugar  in  the 
diet  of  obese  and  diabetic  patients.  Tablets 
containing  Yi  grain  (0.03  Gm.)  of  saccharin 
combined  with  a  small  quantity  of  sodium 
bicarbonate  are  conveniently  carried  by 
these  patients  to  be  used  in  tea,  coffee,  etc. 
It  may  also  be  prescribed  in  the  form  of 
a  syrup  containing  10  parts  of  saccharin 
and  12  parts  of  sodium  bicarbonate  in  1000 
parts  of  distilled  water,  made  with  gentle 
heat  at  104°  F.  (40°  C).  Saccharin  in  small 
doses  has  been  used  in  acid  dyspepsia  and 
in  chronic  cystitis  with  ammoniacal  urine. 
Two  parts  of  saccharin  in  solution  with 
3  parts  of  sodium  bicarbonatei  forms  a 
good  tooth-wash.  Aphthae  yields  to  sac- 
charin; 15  grains  (1  Gm.)  of  saccharin  are 
dissolved  in  IJ/2  ounces  (50  c.c.)  of  alcohol, 
of  which  a  teaspoonful  is  added  to  a  half- 
cup  of  water,  and  used  to  wash  the  mouth 
thoroughly  four  or  five  times  a  day.  It 
may  be  used  to  cover  the  taste  of  quinine, 
1  part  of  saccharin  to  2  of  quinine  be- 
ing used.  As  saccharin  retards  the  action 
of  all  the  digestive  ferments,  it  is  contra- 
indicated  in  cases  in  which  digestion  is 
already  impaired.  W. 


Salicylic  acid,  chemically  ortho-oxy- 
benzoic  acid  [C6H4(OH)COOH]  is 
an  organic  acid  existing  naturally  in 
the  oils  of  wintergreen  (GaiUthcria 
procumbcns)  and  of  sweet  birch 
(Bctula  Icnta)  in  combination  as 
methyl  salicylate.  It  was  first  arti- 
ficially made  in  1874  by  Kolbe,  who 
produced  it  from  phenol,  cailstic  soda, 
and  carbon  dioxide  with  the  aid  of 
moderate  heat  and  subsequent  treat- 
ment with  hydrochloric  acid.  The 
solubility  of  salicylic  acid  in  water, 
normally  relatively  slight,  is  increased 
by  the  addition  of  the  phosphates, 
citrates,  or  acetates  of  the  alkalies, 
and  by  borax  (sodium  biborate). 
Pure  salicylic  acid  should  be  free  from 
color  and  from  the  odor  of  phenol ; 
when  heated  on  platinum  foil,  it 
should  leave  no  ash. 

Various  salts  of  salicylic  acid  are 
official.  There  are  also  in  common 
use  a  number  of  other  substances  con- 
taining the  salicyl  radicle,  including 
such  drugs  as  acetyl-salicylic  acid  and 
salicin.  The  last  named,  a  glucoside 
obtained  from  the  bark  of  several 
species  of  Salix  and  Populiis,  supplied 
the  original  name  for  the  entire  group 
of  drugs,  the  word  salicyl  being 
derived  from  Salix. 

— the  following  salicyl  preparations 
are  official : — 

Acidum  salicylicnm,  U.  S.  P.  (sali- 
cylic acid),  occurring  in  fine  prismatic 
needles  or  a  bulky,  white  powder, 
with  a  slight  odor  of  wintergreen  and 
a  taste  at  first  sweetish,  then  acrid.  It 
is  soluble  in  308  parts  of  water  at  77° 
F.  and  in  14  jxirts  of  boiling  water, 
and  in  2  parts  of  alcohol,  in  60  parts 
of  glycerin,  and  in  2  parts  of  olive  oil 



(with  the  aid  of  heat).  Dose,  5  to  20 
grains  (0.3  to  1.3  Gm.)  ;  average,  7i/2 
grains  (0.5  Gm.). 

Ammonii  salicylas,  U.  S.  P.  (ammo- 
nium saHcylate)  [CcH4(OH)COO- 
NH4],  occurring  in  prisms  or  plates 
or  as  a  white,  crystalHne  powder, 
odorless,  with  a  saline,  bitter  taste 
and  sweetish  after-taste.  It  is  freely 
soluble  in  water  and  alcohol.  Dose, 
3  to  15  grains  (0.2  to  1  Gm.)  ;  aver- 
age 4  grains  (0.25  Gm.). 

Sodii  salicylas,  U.  S.  P.  (sodium  sali- 
cylate) [C6H4(OH)COONa],  a  white 
microcrystalline  or  amorphous  pow- 
der, occasionally  with  a  faint  pink 
coloration,  and  having  a  sweetish, 
saline  taste.  It  is  soluble  in  0.8  part 
of  water  and  in  5.5  parts  of  alcohol, 
and  also  dissolves  in  glycerin.  Dose, 
5  to  20  grains  (0.3  to  1.3  Gm.). 

Strontii  salicylas,  U.  S.  P.  (stron- 
tium salicylate)  [(C6H4(OH)COO)o- 
Sr+2H20],  a  white,  crystalline 
powder  with  a  sweetish,  saline  taste, 
soluble  in  18  parts  of  water  and  in  66 
parts  of  alcohol.  Dose,  5  to  20  grains 
(0.3  to  1.3  Gm.). 

Phenylis  salicylas,  U.  S.  P.  (phenyl 
salicylate;  salol)  [C6H4(OH)COOCg- 
H5],  a  white,  crystalline  powder  with 
a  slightly  aromatic  odor  and  taste, 
practically  insoluble  in  water,  but 
soluble  in  5  parts  of  alcohol  and  freely 
soluble  in  ether,  chloroform,  and  oils. 
Synthetic  or  from  Gaultheria  or  Be  tula. 
Dose,  3  to  15  grains  (0.2  to  1  Gm.)  ; 
average,  7^^  grains  (0.5  Gm.). 

Methylis  salicylas,  U.  S.  P.  (methyl 
salicylate ;  an  artificial  or  synthetic 
oil  of  wintergreen)  [CgH4(OH)- 
COOCHoJ,  a  colorless  liqvud  with  a 
strong  wintergreen  odor,  a  sweetish 
strongly  aromatic  taste,  and  a  specific 
gravity  of  1.18.  It  is  sparingly  soluble 
in  water,  but  dissolves  readily  in  alco- 

hol.    Dose,    5    to    20   minims    (0.3    to 
1.3  c.c).     Chiefly  usecf  externally. 

Salicinitm,  U.  S.  P.  (salicin)  [C13- 
llisOx),  a  glucoside  obtained  from 
several  species  of  the  willow  (Salix) 
and  poplar  (Populus),  occurring  in 
colorless,  silky,  crystalline  needles, 
prisms,  or  a  white,  crystalline  powder, 
odorless,  but  with  a  strongly  bitter 
taste.  It  is  soluble  in  21  parts  of 
water  and  in  71  parts  of  alcohol,  but 
is  insoluble  in  ether  and  chloroform. 
Dose,  10  to  30  grains  (0.6  to  2  Gm.). 

Oleum  betulcc,  U.  S.  P.,  VIII  (oil  of 
betula;  oil  of  birch),  a  volatile  oil 
obtained  by  maceration  and  distilla- 
tion from  the  bark  of  the  sweet  birch, 
Betula  lenta.  Consists  mainly  of 
methyl  salicylate.  Dose,  5  to  20 
minims  (0.3  to  1.3  c.c).  Chiefly 
used  externally. 

Oleum  gaulthericc,  U.  S.  P.  VIII  (oil 
of  gaultheria  or  wintergreen),  a  vola- 
tile oil  di'stilled  from  the  leaves  of 
Gaultheria  procumbens,  consists  mainly 
of  methyl  salicylate.  Dose,  5  to  20 
minims  (0.3  to  1.3  c.c).  Chiefly  used 

Spiritus  gaulthericc,  U.  S.  P.  VIII 
(spirit  of  gaultheria),  made  by  mixing 
5  parts  by  volume  of  oil  of  gaultheria 
with  95  parts  of  alcohol.  Dose,  30 
minims  (2  c.c). 

Bismuth  subsalicylate,  physostig- 
mine  salicylate,  quinine  salicylate,  and 
cafifeine  sodiosalicylate  (N.  F.)  are 
described  in  the  articles  on  Bismuth, 
Physostigma,  Cinchona,  and  Caffeine, 

Among  the  salicylic  preparations 
recognized  in  the  National  Formulary 
are: — 

Lithii  salicylas,  N.  F.  (lithium 
salicylate)  [C6H4(OH)COOLi],  a 
white  or  grayish-white  powder  with 
a    sweetish    taste,    deliquescent    in    a 



moist  atmosphere.  It  is  freely  soluble 
in  water  and  alcohol.  Dose,  5  to  20 
grains  (0.3  to  1.3  Gm.). 

Elixir  litliii  salicylatis,  N.  F.  (elixir 
of  lithimii  salicylate).  Dose,  2  flui- 
drams  (8  c.c),  containing  10  grains 
(0.6  Gm.)  of  lithium  salicylate. 

Elixir  sodii  salicylatis,  N.  F.,  similar 
to  the  preceding. 

Glyccrogclatimim  acidi  salicylici,  N. 
F.  (glycerogelatin  of  salicylic  acid), 
containing  10  per  cent,  of  the  acid. 
Used  locally,  being  melted  by  gentle 
heating  and  applied  with  a  camel's 
hair  brush. 

Liquor  antisepticiis,  N.  F.  (anti- 
septic solution,  Lister),  containing  30 
per  cent,  of  alcohol,  2.5  per  cent,  of 
boric  acid,  0.12  per  cent,  of  methyl 
salicylate  and  of  sodium  salicylate,  0.6 
per  cent,  of  sodium  benzoate,  0.5  per 
cent,  of  eucalyptol,  0.1  per  cent,  of 
thymol,  and  0.03  per  cent,  of  oil  of 
thyme.  Dose,  1  fluidram  (4  c.c). 
Chiefly  used  locally. 

Liquor  antisepticiis  alkalimis,  N.  F. 
(alkaHne  antiseptic  solution),  contain- 
ing 15  per  cent,  of  glycerin,  3.2  per 
cent,  of  potassium  bicarbonate  and  of 
sodium  borate,  0.8  per  cent,  of  sodi- 
um benzoate,  0.04  per  cent,  of  oil  of 
gaultheria,  and  0.02  per  cent,  of  thymol, 
of  eucalyptol,  and  of  oil  of  peppermint, 
colored  purplish  red  with  cudbear;  6 
per  cent,  of  alcohol.  Used  locally, 
diluted  with  2  to  5  parts  of  warm  water. 

Pasta  dnci,  N.  F.  (Lassar's  zinc  or 
zinc-sahcyl  paste),  containing  2  per 
cent,  of  salicylic  acid,  with  zinc  oxide. 
Used  externally. 

Piilvis  antisepticus,  N.  F.  (soluble 
antiseptic  powder),  a  mixture  of 
powdered  boric  acid,  86.6  per  cent.; 
zinc  sulphate,  12.5  per  cent.;  salicylic 
acid,  0.5  per  cent.;  phenol,  eucalyptol, 
menthol,  and  thymol,  of  each  0.1  per 

cent.  Used  as  dusting  powder  or  in 
5  per  cent,  solution. 

Pulvis  talci  composites,  N.  F.  (sali- 
cylated  talcum  powder),  consisting  of 
salicylic  acid,  3  parts;  boric  acid,  10 
parts,  and  powdered  talc,  87  parts. 
Used  as  dusting  powder. 

Mulla  acidi  salicylici,  N.  F.  (salicy- 
lated  salve  mull  or  ointment),  a  10 
per  cent,  preparation  of  salicylic  acid 
in  benzoinated  lard  and  suet,  spread 
on  gauze  or  mull,  to  be  applied  to  the 
skin  where  penetration  by  the  sali- 
cylic acid  is  desired. 

Mulla  creosoti  salicylata,  N.  F. 
(salicylated  creosote  salve  mull),  like 
the  preceding,  with  addition  of  20  per 
cent,  of  creosote. 


— Among  the  unofiicial  salicylic  prep- 
arations used  internally  are  : — 

Acetylsalicylic  acid  (aspirin)  \Cq- 
H4.0(CH3CO).COOH],  occurring  in 
colorless,  crystalline  needles  with  an 
acidulous  taste,  soluble  in  100  parts 
of  water,  and  freely  soluble  in  alcohol. 
Salicylic  acid  is  liberated  from  it  in 
the  intestine.  It  causes  less  sweat- 
ing than  the  ordinary  salicylates. 
Dose,  5  to  30  grains  (0.3  to  2  Gm.). 

Diaspirin  (succinic  ester  of  salicyl- 
ic acid)  [CoH4(COO.C6H4COOH)2], 
a  white  powder  with  slightly  acid 
taste,  sparingly  soluble  in  water, 
easily  soluble  in  alcohol.  Dose,  5  to 
30  grains  (0.3  to  2  Gm.).  Stronger 
than  novaspirin,  but  has  marked 
sudorific  power    (Klaveness). 

Novaspirin  (methylene  citrylsali- 
cylic  acid),  a  white,  crystalline  pow- 
der with  a  faint  acidulous  taste, 
scarcely  soluble  in  water,  freely  solu- 
ble in  alcohol.  Contains  62  per  cent, 
of  salicylic  acid.  Dose,  10  to  30 
grains    0.6    to    2    Gm.).     Weaker    in 


action  than  the  preceding-,  though  bet- 
ter tolerated  l)y  sensitive  patients. 

Salicylosalicylic  acid  (diplosal ; 
salicylic  ester  of  salicylic  acid)  [Cq- 
H4(COO)OH.COOH.CcH4],  a  color- 
less, tasteless  powder,  almost  insolu- 
ble in  water,  readily  soluble  in  dilute 
alkalies.  It  yields  1.07  times  as  much 
jf  the  salicyl  group  in  the  organism 
as  salicylic  acid  itself,  owing  to  the 
fact  that  in  its  molecule  two  mole- 
cules of  salicylic  acid  are  present  in 
condensed  form,  one  molecule  of 
water  (HoO)  having  been  eliminated. 
It  is  unirritating  to  the  stomach  and 
is  absorbed  from  the  intestine.  Dose, 
5  to  20  grains  (0.3  to  1.3  Gm.). 

Antipyrin  salicylate  (salipyrin) 
[CiiHioNoO.CcHiOH.COOH],  a 
white,  crystalline  powder,  slightly 
sweetish,  soluble  in  200  parts  of  w^ater, 
readily  soluble  in  alcohol.  Acids 
liberate  salicylic  acid  from  it,  and 
alkalies,  antipyrin.  Dose,  5  to  15 
grains  (0.3  to  1  Gm.). 

Ferric  salicylate  (iron  salicylate) 
[Feo(OOC(OH)C6H4)3],  a  reddish- 
brown  or  violet-gray  powder,  spar- 
ingly soluble  in  water,  readily  soluble 
in  a  solution  of  potassium  bicarbonate. 
Dose,  3  to  10  grains  (0.2  to  0.6  Gm.). 

Guaiacol  salicylate  (guaiacyl  salicy- 
late; guaiacol-salol)  [C6H4.OH.COO- 
(C6H4.OCH3)],  a  white,  crystalline, 
tasteless  powder,  insoluble  in  water, 
soluble  in  alcohol.  Decomposed  by 
alkalies.  Analogous  to  phenyl  sali- 
cylate (salol).  Dose,  5  to  15  grains 
(0.3  to  1  Gm.). 

Naphthol  salicylate  (betol ;  naph- 
thalol ;  betanaphthyl  salicylate  ;  naph- 
thol-salol)  [C6H4-OH.COO(CioH7)], 
a  white,  shining,  tasteless,  crystalline 
powder  insoluble  in  water,  with  diffi- 
culty solube  in  alcohol.  Decomposed 
when  treated  with  alkalies.     Split  up 

in  the  intestine  by  the  pancreatic  juice 
and  intestinal  secretions.  Dose,  4  to 
8  grains  (0.25  to  0.5  Gm.). 

Quinine  salicylate  (saloquinine ; 
salicyl  quinine),  a  white,  crystalline 
powder,  tasteless,  insoluble  in  water, 
moderately  soluble  in  alcohol,  and 
containing  73.1  per  cent,  of  quinine. 
Dose,  5  to  30  grains  (0.3  to  2  Gm.). 

Santalol  salicylate  (santyl ;  santalyl 
salicylate),  a  yellowish  oil  with  faint 
balsamic  odor  and  taste,  soluble  in 
about  10  parts  of  alcohol.  Split  up  in 
the  intestines,  yielding  60  per  cent,  of 
santalol  (santal  oil).  Dose,  8  minims 
(0.5  c.c). 

Unofficial  salicylic  preparations 
used  externally :  Ethyl  salicylate  (sal 
ethyl)  [C0H4.OH.c6o.C2H5],  a  col- 
orless, volatile  fluid  with  a  pleasant 
odor  and  taste,  insoluble  in  water, 
soluble  in  alcohol.  Analogous  to 
methyl  salicylate.  ]\Iay  be  used  both 
externallv  and  internallv. 

Mesotan  (methyl-oxymethyl  salicy- 
late; ericin)  [C6H4.0H.Cob(CH2.- 
O.CH3)],  a  yellowish,  faintly  aro- 
matic^ oily  fluid,  but  little  soluble  in 
water,  soluble  in  alcohol,  miscible 
with  oils.  To  be  applied,  diluted 
with  an  equal  volume  of  olive  oil,  to 
the  skin,  avoiding  friction,  as  meso- 
tan is  somewhat  irritating. 

Salophen  '  (acet3'lparamidophenol 
salicylate),  a  white,  tasteless,  crystal- 
line powder,  almost  insoluble  in  cold 
water,  freely  soluble  in  alkaline  solu- 
tions, and  in  alcohol.  It  contains  51 
per  cent,  of  salicylic  acid.  It  is  broken 
up  in  the  intestine,  liberating  salicylic 
acid,  and  acetylparamidophenol. 
Dose,  5  to  20  grains  (0.3  to  1.3  Gm.). 
Used  externally  in  a  10  per  cent,  oint- 
ment in  itching  skin  affections. 

Spirosal  (monoglycol  salicylate) 
[C6H4.0H.COO(CH2.CH2.0H)],  an 


oily,  almost  odorless  fluid,  soluble  in  tation,  and  an  appropriate  amount 
about  110  parts  of  water,  freely  solu-  ordered  mixed  with  some  sparkling 
ble  in  alcohol.  To  be  applied  to  the  water  at  each  dose.  An  effervescent 
skin  undiluted,  mixed  with  3  parts  of  preparation  may  be  secured  by  pre- 
alcohol  or  8  parts  of  olive  oil,  or  in  scribed  equal  amounts  of  salicylic 
a  50  per  cent,  petrolatum  ointment,  acid  and  sodium  bicarbonate  in  pow- 
It  is  absorbed  through  the  skin  with-  ders,  to  be  dissolved  in  water  and 
out  irritation  and  sets  free  salicylic  taken  when  the  effervescence  begins 
acid  in  the  tissues.  to  subside.  Small  doses  of  sodium 
INCOMPATIBILITIES.— Salicy-  salicylate  may  be  given  in  capsules, 
lates  are  incompatible  with  mineral  to  be  taken  only  during  or  after 
acids,  which  set  free  the  relatively  meals.  Strontium  salicylate  is  pre- 
insoluble  salicylic  acid  by  combining  ferred  by  some  to  the  sodium  salt, 
with  the  basic  element.  They  are  Oil  of  gaultheria  (wintergreen)  or 
also  incompatible  with  sweet  spirit  of  methyl  salicylate  may  also  be  sub- 
niter,  with  lime-water,  and  with  qui-  stituted  for  it,  given  in  elastic  cap- 
nine  salts,  ferric  salts,  lead  acetate,  sules  during  or  after  meals, 
and  silver  nitrate  in  solution,  as  well  The  co-operative  investigation  of 
as  with  sodium  phosphate  in  powder  the  eft'ects  of  synthetic  sodium  sali- 
form.  Mixtures  of  quinine  and  cylate  and  sodium  salicylate  prepared 
acetylsalicylic  acid  are  dangerous,  de-  from  natural  sources,  reported  by 
veloping  after  a  time  the  poisonous  Hewlett,  and  based  on  about  230  sep- 
substance  quinotoxin,  which  resem-  arate  observations,  showed  that,  from 
bles  digitoxin  in  its  action.  This  toxic  the  clinical  standpoint  there  is  no 
change  develops  even  more  readily  in  essential  difference  between  the  two 
a  mixture  of  cinchona  and  acetyl-  varieties  of  the  drug.  According  to 
salicylic  acid,  and  also  in  elixirs  and  Pulliam,  gastric  irritation  by  sodium 
syrups  containing  quinine  in  acid  salicylate  may  be  due  to  deteriora- 
solution.  tion,  moisture  gradually  decomposing 
MODES  OF  ADMINISTRATION,  the  salt  with  liberation  of  sodium  hy- 
— Salicylic  acid,  which  is  irritating  to  droxide  and  salicylic  acid, 
mucous  surfaces,  should  always  be  Where  sodium  salicylate  given  as 
given  in  solution,  preferably  with  above  described  is  badly  tolerated  by 
potassium  citrate  or  acetate,  or  am-  the  patient,  resort  may  be  had  to  such 
monium  acetate  or  phosphate,  all  of  preparations  as  acetylsalicylic  acid, 
which  increase  its  solubility  in  water,  salophen,  diaspirin,  and  novaspirin, 
Or,  it  may  be  given  in  a  syrup,  which  liberate  the  salicyl  group  only 
flavored  with  compound  spirit  of  in  the  intestine  (and  therefore  have 
lavender,  or  in  elixir  of  orange.  Pref-  the  disadvantage  of  acting  more 
arable  to  the  acid,  however,  is  sodium  slowly  and  often  less  powerfully), 
salicylate,  which,  though  less  irritat-  or  to  salicin,  given  in  generous  dos- 
ing, should  likewise  be  given  in  solu-  age.  Or,  the  cutaneous,  rectal,  hypo- 
tion.  The  salt  may,  for  example,  be  dermic,  or  intravenous  routes  of  ad- 
prcscribed  in  5  parts  of  Aqua  men-  ministration  may  be  partly  or  wholly 
thae  piperitae  or  Aqua  gaultherise,  with  relied  on. 
a  little  glycerin  added  to  reduce  irri-  For  application  to  rheumatic  joints 



methyl  salicylate  or  oil  of  gaultheria  after  it  acts  by  the  salicylate  enema, 

is  generally  used,  either  undiluted,  on  g'^'^'"  ^ith  the  Davidson  syringe  and 

,  ^      1        .       ^.                  1  I      1  •     •        „„ii  a  rectal  tube   inserted  6  to  8  inches, 

absorl^ent  cotton  or  rubi)ed  ni  ni  small  .r^,      ,             •         •  ,     , 

i  no  dose  varies  with  the  weight  and 

amounts,  or  diluted  with  an  equal  part  ,,^  .„,^,  t,,^  severity  of  the  case.    The 

of    olive    oil    or    2    or    more    parts    of  first  adult  dose  in  men  is  usually  from 

petrolatum,    chloroform    liniment,    or  8  to  10  Gm.  (2  to  2>4  drams),  in  women 

soap  liniment.     To  prevent  evapora-  6  Gm.   {\y,  drams).     The  drug  to  be 

.■             r    ,1           -1           -1     1       -11                  .„  given    is    incorporated    in    120   to    180 

tion    of   the   oils,   oiled    silk   or   some  ,,       .              .     ^    ,  . 

.               .                         .  c.c.  (4  to  6  ounces)  of  plain  or  starch 

otiier    impervious    covering    may    be  ^^^^^^   ^^-^^^   the   addition   of   1   to   L5 

used.  Where  these  oils  are  not  at  Gm.  (15  to  23  ounces)  of  opium  tine- 
hand,  absorption  of  salicylic  acid  it-  ture.  The  dose  may  be  repeated 
self  may  be  secured  bv  rubbing  in  for  within  twelve  hours,  but  usually  a 
a  few  minutes  a  tal^lespoonful  of  a  daily  enema  suffices,  with  doses  in- 
.  ,  .  ,  .  ,  .  _  creasing  perhaps  from  30  to  50  per 
mixture    of    1    part    of    the    acid    m    b  ^^^^    j^j,y  ^^^jj  ^^e  limit  of  tolerance 

parts   of  alcohol  and   10  parts  of  cas-  is    reached.      The    largest    daily   dose 

tor  oil  (Cullen),  or  an  ointment  com-  given   was   24   Gm.    (6   drams).     The 

posed    of    salicylic    acid    and    oil    of  o"ly  symptoms  of  salicylism  usually 

turpentine,    of    each    1    part,    and    hy-  appearing    were    tinnitus    and    exces- 

,           ,             ,   r         o                   ^T-.        1        N  sive  perspiration.     The  ready  absorp- 

drated   wool-fat,   8   parts    (Bracken).  ,.                 u          u           ^           t      ■ 

^         i-              \                   '  tion    was    shown   by    a    strong    ferric 

The     efficiency     of    either     of     these  chloride  reaction  in  the  urine  within 

methods   is   shown   by   the  disappear-  thirty  minutes.     It  would   seem  that 

ance  of  joint  pain  and  appearance  of  the   greatest   absorption    of   the   drug 

the   drug  in  the  urine  within   a  few  ^^  ^'^^hin  twelve  hours.    L.  G.  Heyn 

r^^-,          ,1                   c        ^^  (Tour.   Amer.   Med.   Assoc,   Sept.    19, 

minutes.      Other    local    uses    of   sail-  ,g. . 

cylates  are  described  in  the  section  on 

Therapeutics  '^^^    hypodermic    and    intravenous 

For  rectal  administration  of  sodium  ^^^^^^  ^^^^'^  '^^e"  ^^'^'^^^  o^'  ^""'^^  §^oo^ 
salicylate  the  following  formula,  ''^^^^t^'  ^^^  ^^^^ert  and  by  Mendel, 
recommended    by    Crouzet,    may    be      Rubens,   and   Conner,   respectively, 

employed  : Intravenous  injection   of  salicylates 

■D    c  J--      T     1  J-                 .%      /le  /"     \  strongly    recommended.      The    prep- 

-r>  Sodii  sahcylafis 5ss   (15  Gm.).  .               ,            . 

A       •,,;„•                 7-    //(  r-     ^  aration   used    consists    of: — 

Acacia  piilveris 3j    (4  Gm.). 

Lactis    fSiv  (120  Gm.).  Sodium  salicylate   2  dr.   (8  Gm.) 

Fiat  mistura.  Caffeine  sodiosalicyl.. .   Yi  dr.   (2  Gm.). 

T-i  .    ^  ,    '  'its  '  Sterile  water 1^  oz.  (45  c.c). 

1  he     mixture     contains     30     grains 

(2  Gm.)  of  sodium  salicylate  to  the  One-half  dram    (2  c.c)    is   injected 

tablespoonful,    is  well   tolerated,   and  *^.^*=^   ^  f'^-    /'    ^^l  '"'"^^'    J°^"* 

,          .              ,  ,-7  •                        1-  pains    and    exudates    disappear    even 

can  be  given  ad  libitum,  according  to  ,              j-              r     i  *     ^      4.        ^ 

o                                '                    ^  where    ordinary    salicylate    treatment 

the  requirements  of  the  case,  with  a  f^iis.     a  single  dose  causes  marked 
glass  syringe  or  the  ordinary  rubber  improvement.     None  of  the  unpleas- 
enema  bulb.  ant    actions     of    salicylates     are     en- 
Intrarectal     administration     of     so-  countered.     Cases  which  do  not  react 
dium    salicylate   recommended   in    re-  are  not  rheumatic.     This  is  the  most 
fractory  cases  of  acute  and  subacute  certain  method  of  diagnosing  the  ex- 
rheumatism    from    experience    in    125  act     nature     of     doubtful     rheumatic 
cases.     A   cleansing   soapsuds   enema  cases,   especially   in   diagnosing  early 
is    given    and    followed    immediately  tuberculous  and  rheumatoid  arthritis 



from  true  rheumatic  cases.  F.  Men- 
del (Miinch.  med.  Woch.,  p.  165, 

The  writer  injects  10  c.c.  (2J^ 
drams)  of  a  20  per  cent,  sterilized 
solution  of  sodium  salicylate  per  100 
pounds  of  body  weight  for  acute 
rheumatic  infections  of  joints,  heart, 
pericardium  and  pleura.  He  first  uses 
a  hypodermic  injection  of  cocaine 
and  fifteen  minutes  later  injects  in  the 
same  spot  the  sodium  salicylate.  The 
dose  is  repeated  every  twelve  hours. 
In  severe  cases  with  multiple  lesions 
15  c.c.  (4  drams)  to  each  100  pounds 
of  body  weight  is  advised.  Within 
three  hours  after  the  first  injection, 
pain,  fever,  joint  stiffness  and  pulse 
rate  diminish.  This  improvement 
continues  if  the  injections  are  re- 
peated every  twelve  hours,  but  if 
omitted  the  conditions   grow   worse. 

In  chronic  cases,  10  c.c.  (2^  drams) 
per  100  pounds  of  body  weight  of  the 
following  oily  solution  are  injected 
every  twenty-four  hours:  Salicylic 
acid,  10  Gm.  (2>^  drams) ;  sesame  oil, 
80  Gm.  (2%  ounces) ;  pure  alcohol,  5 
Gm.  (l]4  drams);  and  gum  camphor, 
5  Gm.  (1j4  drams).  This  is  sterilized 
before  the  alcohol  is  added.  It  must 
not  be  exposed  to  the  air,  as  the 
alcohol  will  evaporate  and  the  sali- 
cylic acid  precipitate.  The  effect  in 
chronic  cases  is  more  rapid  when 
multiple  localizations  of  the  rheu- 
matic process  exist  than  when  one 
joint  is  affected.  In  the  former,  pain 
and  stiffness  usually  improve  after 
the  first  injection;  in  the  latter,  after 
the  third.  Addition  of  camphor  (5 
to  20  per  cent.)  was  found  beneficial 
in  stimulating  the  heart  when  the 
pericardium  or  endocardium  was  in- 
volved. With  this  method  there  is 
entire  absence  of  the  toxic  symptoms 
seen  when  salicylates  are  given  by 
mouth.  Siebert  (Med.  Rec,  Mar.  11, 

The  rapidity  of  absorption  of 
sodium  salicylate  when  given  sub- 
cutaneously  is  about  the  same  as  by 
other  routes,  but  its  concentration  in 
the  blood  does  not  reach  one-half  of 

that  when  it  is  given  intramuscularly. 
Sodium  salicylate  disappears  from 
the  blood  in  ten  hours  when  given 
subcutaneously;  if  given  per  os  it  is 
present  in  the  blood  after  twenty- 
four  hours.  E.  Levin  (Dent.  med. 
Woch.,   Dec.   19,   1912). 

Administration  of  sodium  sali- 
cylate by  intravenous  injections  is 
safe,  painless,  and  easily  performed. 
The  drug  seems  to  have  a  much  more 
pronounced  analgesic  effect  than 
when  givent  by  mouth.  The  solution 
for  injection  is  made  by  dissolving 
10  Gm.  (2^  drams)  of  chemically 
pure  crystalline  sodiuin  salicylate  in 
50  c.c.  (1%  ounces)  of  distilled  water, 
freshly  sterilized  by  boiling.  In  most 
cases  the  dose  has  been  either  15  or 
20  grains  (1  or  1.3  Gm.)  and  the  in- 
jections given  at  twelve-  or  eight- 
hour  intervals  over  a  period  of  three 
to  six  days.  Occasionally,  in  robust 
men,  as  much  as  30  grains  (2  Gm.) 
have  been  given  at  a  time,  and  as 
much  as  120  grains  (8  Gm.)  given  in 
the  first  twenty-four  hours  without 
any  unpleasant  effects.  The  field  of 
indication  for  the  intravenous  method 
includes  cases  in  which  the  drug  is 
not  well  borne  by  the  stomach;  those 
which  show  little  or  no  improvement 
under  the  usual  methods  and,  pos- 
sibly, cases  of  severe  rheumatic  in- 
flammation of  the  eye.  Conner  (Med. 
Record,  Ixxxv,  323,   1914). 

Case  of  a  man  of  25  with  extremely 
severe  febrile  rheumatism  involving 
all  the  joints,  with  mj'^ocarditis  and 
dyspnea;  the  stomach  being  abso- 
lutely intolerant  for  the  salicylates. 
The  writer  gave  an  intravenous  in- 
jection of  6  c.c.  (1^  drams)  of  a 
mixture  of  5  Gm.  (1^4  drams)  sodium 
salicylate  and  0.25  Gm.  (4  grains) 
caffeine  in  25  Gm.  (6  drams)  distilled 
water.  The  injection  was  repeated 
daily  for  six  days,  increasing  the 
amount  from  1.2  to  2  Gm.  (20  to  32 
minims).  By  the  fourth  day  the  man 
was  able  to  sit  up,  with  normal  tem- 
perature, pulse  84,  and  no  further 
precordial  distress.  Cernadas  (Se- 
mana  Medica,  Dec.  23,  1915). 


Phenyl  salicylate  (salol),  in  its 
usual  dosage  of  5  or  7^  grains  (0.3 
or  0.5  Gm.)  every  three  or  four  hours, 
exerts  but  little  of  the  effect  of  sali- 
cylates and  rather  acts  like  phenol, 
which  it  gives  ofif  in  the  intestinal 
tract.  Large  doses  of  phenyl  sali- 
cylate are,  as  a  rule,  to  be  avoided, 
as  they  may  induce  symptoms  of 
phenol  poisoning,  and  darken  the 
urine.  It  may  be  given  in  capsules, 
in  taljlets,  or  combined,  for  example, 
with  bismuth  salts,  in  powders.  It  is 
almost  insoluble  in  the  gastric  juice, 
and  does  not  irritate  the  stomach. 

cylates are  contraindicated  except 
sometimes  when  used  for  local  pur- 
poses, in  middle-ear  disease,  and  in 
conditions  associated  with  impaired 
renal  functioning,  as  in  pregnancy 
and  chronic  nephritis.  Albuminuria 
is  a  contraindication,  except  in  renal 
disturbance  of  rheumatic  origin, 
though  in  infections  of  the  urinary 
tract  phen)^  salicylate  is  used.  Sali- 
cylates should  not  be  administered  to 
pregnant  women  who  have  a  tend- 
ency to  abort,  nor  in  women  with 
metrorrhagia  or  menorrhagia.  Where 
there  is  circulatory  depression,  some 
degree  of  caution  as  to  the  dosage  of 
salicylates  is  required. 

Prolonged  administration  of  sali- 
cylates in  large  dosage  is  unwise, 
causing  debility,  anemia,  and  a  ten- 
dency to  hemorrhage  from  the  mu- 
cous membranes. 

Externally,  salicylic  acid  is  an  irritant, 
especially  to  mucous  membranes. 
Carefully  applied  to  the  skin  it  is 
capable  of  softening  the  epidermis  or 
accumulations  of  horny  epithelium 
without  inducing  inflammation.  It 
also    tends    to   arrest    local    sweating 

and  to  promote  the  growth  of  normal 
skin  in  chronic  skin  affections.  It  is 
an  antiseptic,  stronger  than  acetani- 
]ide  and  rivalling  phenol,  over  which 
it  has  the  advantage  of  not  volatiliz- 
ing. The  salts  of  salicylic  acid  are 
less  irritating  than  the  free  acid,  and 
also  much  less  strongly  antiseptic. 
The  liquid  salicylates,  such  as  methyl 
salicylate  and  the  oils  of  wintergreen 
and  birch,  are,  however,  useful  as 

General  Effects. — Nervous  System. 
— The  chief  nervous  effects  of  sali- 
cylates is  manifest  in  relief  from  pain, 
probably  due,  as  in  the  case  of 
acetanilide  and  its  congeners,  either 
to  constriction  of  vessels  loco  doleiiti 
or  to  direct  depression  of  the  sensory 
nerve-cells  in  the  optic  thalami. 

Circulation. — Small  doses,  if  any- 
thing, slightly  raise  the  blood-pres- 
sure (chiefly  by  central  vasoconstric- 
tion) and  accelerate  the  heart. 
Large  doses  directly  depress  the 
heart.  The  skin-vessels  are  dilated 
by  all  doses.  According  to  some  the 
number  of  leucocytes  in  the  blood 
shows  a  marked  increase,  returning 
to  normal,  however,  after  a  single 
dose,  within  two  hours. 

Alimentary  Tract.— ^Idiny  of  the 
salicylates,  especially  the  free  acid, 
act  as  irritants  in  the  stomach. 
Acetylsalicylic  acid,  phenyl  salicylate 
(salol)  and  salicin,  however,  may  not. 
passing  through  the  stomach  un- 
changed and  only  setting  free  the 
salicyl  group  in  the  intestine.  Sali- 
cylic acid  tends  to  arrest  ferment 
action,  interfering,  therefore,  with  the 
digestive  processes.  It  is  claimed 
that  intestinal  putrefaction  can  be  re- 
duced with  it,  and,  according  to  some, 
large  doses  of  salicylates  stimulate 
the  formation  of  bile. 


Temperature. — Salicylates  lower  the 
temperature  where  there  is  fever,  like 
antipyrin,  but  act  less  strongly.  The 
effect  is,  at  least  in  part,  due  to  pe- 
ripheral vasodilatation  and  sweating, 
which  increase  heat  loss.  A  direct 
action  on  the  heat  centers  has  not  as 
yet  been  proved  to  occur. 

Metabolism. — Augmented  destruc- 
tion of  protein  is  caused  by  the  sali- 
cylates, as  shown  by  a  distinct  in- 
crease in  the  output  of  urea,  uric  acid, 
and  sulphur-bearing  compounds  in 
the  urine. 

The  increased  output  of  uric  acid 
following  salicylate  medication  is 
due  to  a  lowered  threshold  value  of 
the  kidney,  not  only  for  uric  acid, 
but  in  all  probability  for  other  waste 
products  as  well.  Such  being  the 
case,  it  may  well  be  that  the  bene- 
ficial effects  resulting  from  the  use 
of  salicylates  in  acute  rheumatic 
fever  may,  in  part  at  least,  be  due  to 
a  power  possessed  by  this  class  of 
drugs  of  increasing  kidney  permea- 
bility, thereby  facilitating  the  rapid 
and  more  or  less  complete  excretion 
of  the  toxins  which  produce  symp- 
toms of  these  diseases.  Denis  (Jour. 
Pharmacol,  and  Exper.  Therap.,  Oct., 

Absorption  and  Elimination. — Sali- 
cylates are  rapidly  absorbed  from  the 
stomach  and  duodenum,  and  circulate 
in  the  blood  as  salicylates  of  the  alka- 
lies. Excretion  is  also  rather  rapid, 
and  takes  place  chiefly  through  the 
kidneys,  which  are  irritated  by  large 
doses  and  sometimes  react,  even  after 
moderate  doses,  by  a  diuresis.  The 
chief  product  in  salicylic  elimination 
has  long  been  considered  to  be  salicyl- 
uric acid,  an  inert  compound  with  gly- 
cocoll  yielding  a  violet-red  color  with 
ferric  chloride.  Studies  by  Hanzlik 
(191.S),  however,  cast  doubt  upon  the 
elimination  of  salicyluric  acid  in  man, 
products   free   of  glycocol),   and   pre- 

sumed to  be  in  part  an  impure  sali- 
cylic acid,  being  alone  found.  Small 
amounts  of  salicylates  ingested  are 
eliminated  with  the  bile,  sweat,  and 
mammary  secretion. 

POISONING. — Overdoses  of  salicylic 
preparations  produce  symptoms  simu- 
lating cinchonism,  viz.,  a  feeling  of 
fullness  in  the  head,  tinnitus  aurium 
and,  perhaps,  slight  dizziness.  Other 
signs  of  overdosage  are  gastric  irri- 
tability, nausea  and  vomiting;  head- 
ache ;  inental  dullness  and  apathy,  and 
impairment  of  hearing  or  vision,  due 
either  to  local  circulatory  modifica- 
tions or  to  degenerative  changes  in- 
duced in  the  cochlear  or  retinal  nerve- 
cells  or  in  the  optic  nerve.  After  very 
large  doses  complete  deafness  or 
blindness  may  occur.  According  to 
Drayer,  15  grains  (1  Gm.)  4  times  a 
day  for  a  week  will  often  produce 
deafness  lasting  four  months. 

In  some  cases  of  salicylism,  mental 
excitation  is  a  feature — the  "salicylic 
jag."      The    cerebral    symptoms    are 
similar  to  those  induced  by  atropine, 
— talkativeness  and  great  cheerfulness 
passing  on  to  delirium  with  halluci- 
nations and  motor  restlessness.     De- 
lirium is  an  especially  common  symp- 
tom among  drunkards.      Mental   dis- 
turbance may  persist  a  week  or  more. 
A    number    of    patients    taking    sali- 
cylates   experienced    auditory    hallu- 
cinations.   Long- forgotten  memories  of 
certain  sounds  were  aroused  :    the  roar 
of  a   certain   water-fall,   the  singing  of 
birds    heard    in    a    certain    garden,    etc. 
The  drug  reaching  the  cells  seemed  to 
bridge     the    gap    between     unconscious 
and  conscious  memories.    Seitz   (Corre- 
spondenzbl.    f.    schweizer    Aerzte,    Apr. 
1,  1909). 

Poisonous    doses    of    salicylic    acid 
induce  l)urnin--  in  the  throat,  nausea 


and  vomiting,  sometimes  diarrhea; 
special  sense  disturbances,  sometimes 
with  mydriasis,  ptosis,  or  stralMsmus ; 
thirst;  precordial  oppression;  feeble 
heart  action  and  vasomotor  weakness; 
sweating;  marked  dyspnea;  prostra- 
tion ;  greenish  urine,  and  occasionally 
albuminuria,  hematuria,  or  even  sup- 
pression of  urine ;  coma.  Death,  when 
it  occurs,  is  due  to  respiratory  paraly- 
sis, and  may  be  preceded  by  general 

A  girl,  aged  10  years,  had  been  suf- 
fering from  acute  rheumatism  for 
three  days.  Endocarditis  developed. 
A  purgative  was  given  and  then  IS 
grains  (1  Gm.)  of  sodium  salicylate 
with  double  that  amount  of  sodium 
bicarbonate  every  four  hours,  for 
four  days,  when  the  child  became 
delirious  and  vomited  twice.  The 
salicylate  was  withdrawn  and  the  de- 
lirium quickly  passed  ofif.  On  the 
fourth  day  after  admission  the  tem- 
perature, pulse,  and  respirations  were 

Later,  the  patient  again  complained 
of  joint  pains  and  salicylates  were  re- 
sumed (7  grains — 0.45  Gm. — in  water 
3  times  a  day).  After  two  days  she 
again  vomited.  There  was  no  deliri- 
um, but  the  urine  contained  sufficient 
blood  to  give  it  a  deep-red  color.  She 
also  complained  of  severe  pain  along 
the  left  iliac  crest,  and  there  was 
much  tenderness  in  the  left  renal  re- 
gion. Salicylates  being  discontinued, 
the  urine  was  clear  in  four  days,  con- 
taining neither  blood  nor  albumin, 
and  the  pain  had  also  disappeared. 
The  pain  was  probably  a  "referred 
pain"  from  the  kidney.  J.  D.  Mar- 
shall (Lancet,  Feb.  2,  1907). 

The  dosage  of  salicylic  preparations 
necessary  to  induce  circulatory  de- 
pression is  relatively  large,  20  grains 
of  sodium  salicylate,  repeated  at  inter- 
vals of  two  or  three  hours,  rarely 
having  an  appreciable  action  on  the 
pulse  and  blood-pressure. 

The  primary  effect  of  salicylates  is 
on  the  temperature,  which  drops  sud- 
denly owing  to  increased  heat  radia- 
tion through  the  dilated  capillaries. 
The  resulting  depression  of  the  nerv- 
ous system  determines  the  collapse. 
These  drugs  should  be  given  in  small 
doses,  frequently  repeated,  to  avoid 
rapid  temperature  reduction.  Bovisoff 
(Roussky   Vratch,    Feb.   23,    1913). 

Experiments  showing  that  solu- 
tions of  sodium  salicylate  gradually 
deteriorate  on  standing,  the  loss  be- 
ing greater  in  the  weaker  solutions. 
About  20  per  cent,  is  destroyed  in  the 
body,  and  40  per  cent,  when  there  is 
fever,  alcoholism,  morphinism,  or 
exophthalmic  goiter.  Hanzlick  and 
Wetzel  (Jour,  of  Pharm.  and  Ex- 
perim.   Therap.,   Sept.,   1919). 

Erythema  with  edema,  intolerable 
itching  and  tingling  of  the  skin,  and 
fever,  have  been  catised  by  large  doses 
of  sodium  salicylate.  Other  possible 
effects  are  transitory  dark-colored 
spots,  ecchymoses,  vesicles  and  pus- 

According  to  Martinet,  sodium  sali- 
cylate sometimes  induces  in  children 
symptoms  similar  to  those  of  diabetic 
acidosis.  Sodium  bicarbonate  in  large 
doses  and  catharsis  are  advocated  in 
the  treatment. 

A  chronic  form  of  salicylic  poison- 
ing has  been  met  with  in  persons  ex- 
posed to  inhalation  of  the  acid, 
marked  by  a  subacute  inflammation 
of  the  air-passages,  sometimes  with  a 
serious  degree  edema.  In  these  in- 
stances potassium  iodide  is  beneficial. 
Chronic  absorption  from  food  or  drink 
preserved  with  salicylic  acid  may  re- 
sult in  constipation  alternating  with 
diarrhea,  mental  depression,  skin 
eruptions,  and  albuminuria. 

— The  tinnitus  caused  by  salicylic 
acid  may  be  relieved  by  a  20-grain 
(1.3  Gm.)  dose  of  sodium  bromide.  In 


the  treatment  of  salicylism,  the  giving 
of  large  doses  of  sodium  bicarbonate 
has  been  recommended  to  hasten 
elimination  of  the  drug.  The  treat- 
ment of  severe  acute  poisoning  is 
largely  symptomatic,  cracked  ice  by 
the  mouth  and  an  ice-bag  or  mustard 
plaster  over  the  epigastrium  being 
used  to  relieve  vomiting,  cold  com- 
presses being  applied  for  headache, 
veronal  or  opiates  given  for  the  rest- 
lessness and  delirium,  and  appropri- 
ate stimulants  for  circulatory  depres- 
sion. As  in  other  forms  of  acute 
poisoning  the  stomach  should  be 
thoroughly  evacuated  with  the 
stomach-tube  or  emetics  and,  if  it 
seems  advisable,  a  purge  given  to 
clear  the  drug  from  the  intestine.  For 
further  suggestions  as  to  treatment 
the  reader  is  referred  to  the  sections 
on  Poisoning  in  the  articles  on  Ace- 


THERAPEUTICS.— Salicylic  acid 
and  its  salts  are  used  for  both  general 
and  local  effects. 

General  Uses. — As  remedies  in 
acute  rheumatism,  the  salicylates 
hold  first  rank  by  reason  of  the 
prompt  relief  of  pain,  fever  and  other 
symptoms  of  this  disease  they  afford. 
Various  methods  of  administration 
have  been  suggested,  some  of  which 
are  referred  to  in  the  article  on  Rheu- 
matic Fever.  Plehn,  among  others, 
lays  stress  on  adequacy  of  dosage, 
giving  even  mild  cases  15  grains  (1 
Gm.)  of  salicylic  acid  6  times  a  day 
(suspending  the  remedy  at  night), 
until  the  temperature  has  remained 
normal  for  three  days,  after  which  a 
few  15-grain  (1  Gm.)  doses  are  given 
daily  for  a  week,  the  patient  then  re- 
maining in  bed  three  days  more,  with- 
out the  remedy.     In  women  the  dos- 

age is  made  smaller — often  only  5  and 
sometimes  only  3  doses  a  day  at  the 
outset.  With  this  treatment,  Plehn 
observed  the  development  of  valvular 
disease  in  only  2  out  of  319  cases 
treated.  Plehn's  dosage,  however, 
seems  somewhat  excessive  from  the 
standpoint  of  special  sense  impair- 
ment and  renal  irritation.  Sodium 
salicylate  is  better  tolerated  by  the 
stomach  than  the  free  acid  and  may 
be  substituted  for  it  for  this  reason. 
Tinnitus  should  be  regarded  as  a 
warning  signal  against  large  dosag-e. 
Homberger  advises  the  combination 
of  sodium  bicarbonate  (1  or  2  parts) 
with  sodium  salicylate,  given  in  solu- 
tion in  a  little  water,  the  purpose 
being  to  prevent  liberation  of  the 
more  irritating  salicylic  acid  from  the 
salicylate  by  the  hydrochloric  acid  of 
the  gastric  juice,  and  simultaneously 
to  accelerate  absorption  of  the  sali- 
cylate by  means  of  the  carbon-dioxide 
gas  evolved.  He  al&o  advises  that  the 
drug  be  given  between  meals,  when 
there  is  least  acid  in  the  stomach,  and 
not  too  freely  diluted,  as  a  large  quan- 
tity of  fluid  will  cause  it  to  be  retained 
longer  in  the  stomach.  Salicylic 
treatment  in  those  with  sensitive 
stomachs  can  likewise  be  carried  out 
with  acetylsalicylic  acid  (aspirin), 
which  sets  free  the  salicyl  group  only 
in  the  intestinal  alkaline  medium. 
Klaveness  prescribes  this  drug  in  15- 
grain  (1  Gm.)  doses  every  two  or 
three  hours,  combined,  in  persons  in 
whom  circulatory  weakness  is  sus- 
pected, with  V/2  grains  (0.1  Gm.)  of 
powdered  ergot.  In  children.  Osier 
is  credited  with  recommending  sali- 
cin  in  full  doses;  Comby  praises  the 
action  of  sodium  salicylate  in  the  dos- 
age of  7  grains  (0.5  Gm.)  a  day  for 
each   year   of  the   child's   age.     The 


rectal,  intravenous,  intramusclar,  and 
percutaneous  methods  of  administer- 
ing salicylates  are  also  available. 

Renal  irritation  from  salicylates, 
manifested  in  slight  albuminuria, 
sometimes  with  a  few  casts,  is  gen- 
erally recognized  to  be  a  temporary 
condition,  though  it  may  persist  for 
weeks  and  even  be  serious  where 
some  degree  of  nephritis  already  ex- 
ists. .Combination  with  sodium  bicar- 
bonate was  found  by  Glaesgen  to 
obviate  renal  irritation  by  the  salicy- 
lates. Acetylsalicylic  acid  is  held 
by  some  to  be  non-irritating  to  the 

In  muscular  rheumatism,  including 
lumbago,  the  salicylates  are  of  value 
in  relieving  the  pain ;  likewise  in  the 
so-called  "growing  pains."  In  gonor- 
rheal rheumatism  their  effect  is  less 
marked.  The  pains  of  chronic  fibro- 
sitis  are  quickly  relieved  by  sodium 
salicylate  combined  with  antipyrin 
(Stark).  In  sciatica  and  other  painful 
rheumatic  nervous  conditions  the  sali- 
cylates are  also  of  distinct  value.  In 
migraine,  a  combination  of  sodium 
salicylate  and  potassium  bromide, 
given  at  the  start  of  the  attack,  often 
yields  a  gratifying  result.  In  rheu- 
matic uveitis  and  scleritis  marked 
benefit  is  obtained  from  15-grain  (1 
Gm.)  doses  of  the  salicylates,  given 
4  times  a  day. 

In  rheumatic  conditions  associated 
with  anemia  the  writer  uses  the  fol- 
lowing mixture:  In  an  8-ounce  (240 
c.c.)  bottle  place  1  dram  (4  Gm.)  of 
sodium  salicylate  and  dissolve  it  in 
about  2  ounces  (60  c.c.)  of  water.  Add 
liquor  ferri  perchloridi  (B.  P.)  Y2 
dram  (2  c.c),  plus  about  an  ounce 
(30  c.c.)  of  water.  This  produces  a 
dark-purple  mixture  with  a  thick, 
curdy  precipitate.  Then  add  1  dram 
(4  Gm.)  of  potassium  bicarbonate 
dissolved  in  1  ounce  (30  c.c.)  of  water, 

and  fill  up  the  bottle  to  8  ounces  (240 
c.c.)  with  water.  The  precipitate  dis- 
solves on  the  addition  of  the  potas- 
sium solution,  and  the  result  is  a  clear 
claret-colored  mixture  of  an  agree- 
able taste. 

The  mixture  was  found  particularly 
useful  in  a  kind  of  sore  throat  ap- 
parently of  rheumatic  origin  (primary 
or  secondary)  with  slight  redness  and 
pain,  especially  on  swallowing.  H. 
Drinkwater  (Liverpool  Medico-Chir. 
Jour.,  July,  1911). 

For  the  relief  of  pain  in  general,  the 
acetyl  preparations  of  salicylic  acid, 
such  as  aspirin  and  diaspirin,  seem 
more  efficient  than  the  other  prepara- 
tions. In  neuralgia,  the  pains  of  tabes 
dorsalis,  and  those  of  peripheral  neuri- 
tis, these  drugs  often  prove  of  value. 
In  mild  forms  of  dysmenorrhea, 
acetylsalicylic  acid  is  a  particularly 
efficient  remedy.  It  may  also  be  used 
in  acute  and  subacute  pelvic  cellulitis, 
salpingitis,  ovaritis,  and  parametritis. 

In  acute  tonsillitis  or  peritonsillitis, 
frequently  rheumatic  in  nature,  sali- 
cylates are  considered  of  value,  re- 
lieving pain  and  swelling,  shortening 
the  period  of  illness,  and  perhaps 
obviating  suppuration  if  given  early. 
In  addition  to  its  internal  use,  garg- 
ling with,  c.  g.,  lyi  io2  drams  (6  to  8 
Gm.)  of  sodium  salicylate  in  6  fluid- 
ounces  (180  c.c.)  of  peppermint-water 
(Cheveller),  or  direct  application  of  a 
salicylate  to  the  tonsils  (Fetterolf), 
has  been  advised. 

Salicylate  of  iron  recommended  in 
erysipelas  and  acute  tonsillitis.  Care 
should  be  taken  in  its  preparation, 
that  the  iron  is  added  to  the  sodium 
salicylate,  otherwise  the  characteris- 
tic reddish-brown  precipitate  does  not 

For  adults,  the  dose  generally  con- 
tains 7H  grains  (0.5  Gm.)  of  sodium 
salicylate  and  potassium  bicarbonate, 
and  7^  minims  (0.45  c.c.)  of  the  B. 
P.  liquor  ferri  perchlor.    The  solution 


is  of  a  clear  violet  color,  and  is  quite 
palatable,  though  it  may  be  sweet- 
ened if  necessary.  It  is  non-depres- 
sant, non-constipating,  and  is  a  well- 
marked  febrifuge.  The  feces  are 
colored  black. 

In  erysipelas  the  mixture  acts  with 
the  greatest  rapidity,  cutting  short 
the  disease,  which  never  lasts  more 
than  10  days,  and  in  most  cases  is 
cured  in  3  or  4.  After  the  first  few 
doses,  there  is  a  striking  alleviation 
of  all  pain.  The  drug  is  administered 
every  three  hours,  the  treatment  be- 
ing commenced  with  a  purgative,  such 
as  calomel.  As  a  rule,  within  24 
hours  the  temperature  is  normal,  the 
disease  has  ceased  to  spread,  and  the 
patient  feels  better. 

The  cases  of  acute  tonsillitis  in 
which  salicylate  of  iron  has  an  ex- 
cellent action  are  probably  those  of 
streptococcal  origin.  It  acts  very 
quickly;  if,  after  3  days,  there  is  no 
marked  improvement,  it  is  not  worth 
while  continuing.  In  a  recent  out- 
break of  sore  throats  at  a  school,  the 
drug  was  markedly  successful  in 
about  50  per  cent,  of  cases. 

In  cases  of  erysipelas  of  great 
severity,  the  writer  often  adds  twice 
the  usual  amount  of  iron,  which  pro- 
duces a  very  dark  solution  but  no 
precipitate,  and  is  much  stronger  in 
its  action  on  the  disease.  M.  C.  S. 
Lawrance    (Practitioner,    Mar.,   1913). 

In  influenza  or  grippe,  Stark  admin- 
isters the  following  after  a  mercurial 
purge  :— 

R  Sodii  salicylatis. 
Potass  a  hicarbona- 

t'ls   aa  gr.  X  (0.6  Gm.) . 

Tiiictitrtc   inicis  vom- 
ica:        TTL  X   (0.6  c.c.) . 

Aq.  chlorof.  ..q.  s.  ad   fSj    (30  c.c). 

M.     Sig. :    Every  two  to  four  hours. 

Good  results  in  pneumonia  of  in- 
fluenzal origin,  in  that  succeeding 
measles,  and  in  pharyngitis,  laryn- 
gitis, and  bronchitis,  Ijy  bical  applica- 
tion of  a  10  per  cent,  solution  of  sal- 
icylic acid  and  of  castor  oil,  respec- 
tively, in  90  per  cent,  alcohol.     In  the 

pneumonic  cases  a  compress  moist- 
ened with  the  solution  was  placed  over 
the  entire  back,  covered  with  imper- 
meable material,  and  held  in  place  by 
a  bandage.  The  dressing  was  renewed 
whenever  it  became  dry.  A  prompt 
and  very  favorable  influence  upon  the 
cough,  temperature,  pulse  and  res- 
piration was  noted.  L.  G.  Boutchin- 
skaia-Yourchevskaia  (Semaine  med., 
Sept.  11,  1912). 

In  acute  coryza,  the  same  author 
recommends  the  following  : — 

R.  Sodii   salicylatis    gr.  x  (0.6  Gm.). 

Spiritus  amnioiiicc  aro- 

matici    f3ss   (2  c.c). 

Tincturcc   belladonmr 

foliorum m. v   (0.3  c.c.) . 

Aq.  chlorof.   ..q.  s.  ad  f5j    (30  c.c). 
M.     Sig. :    Every  four  hours. 

Stark  has  also  found  the  drug  use- 
ful in  mumps,  in  puerperal  fever,  and 
in  "bilious  headache,"  in  the  latter 
condition  combined  with  potassium 

In  gout,  salicylic  acid,  though  in- 
ferior to  colchictim,  may  be  of  value 
for  a  short  time.  It  was  found  by 
Fine  and  Chace  (1915),  to  increase 
the  elimination  of  uric  acid,  some- 
times even  more  than  atophan.  In 
phosphaturia,  sodium  salicylate  will 
clear  up  the  urine  and  arrest  the  reflex 
nerve  pains. 

In  pleural  effusion,  30  to  60  grains 
(2  to  4  Gm.)  of  sodium  salicylate  are 
credited  with  some  power  to  promote 
absorption  of  the  effusion. 

In  diabetes  mellitus,  von  Noorden 
considers  sodium  salicylate  the  most 
useful  of  the  drugs,  with  the  excep- 
tion of  codeine  and  other  nerve 

Chibret  found  sodium  salicylate  in 
a  daily  dosage  of  1  dram  (4  Gm.)  of 
some  value  in  l)ringing  symptomatic 
relief  in  exophthalmic  goiter.  Monae- 
Lesser  observed  that  the  administra- 


tion  of  3  or  4  15-i^rain  (1  Gm.)  doses 
of  sodium  salicylate  in  renal  and  hep- 
atic colic  assisted  the  action  of  opiates 
and,  by  relaxing  the  channels,  favored 
passage  of  the  stones.  The  same 
author  advises  the  giving  of  sodium 
salicylate  by  the  mouth  or  rectum  (15 
grains  every  three  hours)  in  cystitis 
and  acute  prostatitis,  and  treats  acute 
ascending  cellulitis  of  the  extremi- 
ties by  administering  this  salt  intern- 
ally and  applying  locally  an  ointment 
consisting  of  magnesium  carbonate, 
resorcinol,  and  lanum. 

The  value  of  phenyl  salicylate 
(salol)  as  an  antiseptic  acting  in  the 
urinary  passages  is  well  known.  A 
dosage  exceeding  30  grains  (2  Gm.) 
a  day  is  rarely  necessary,  and  is,  in 
fact,  likely  to  produce  untoward  re- 
sults. The  drug  should,  therefore, 
ordinarily  not  be  employed  in  acute 
rheumatism.  It  is  of  value,  however, 
in  gonococcal  urethritis,  in  pyelitis, 
and  in  certain  forms  of  cystitis. 

For  purposes  of  intestinal  antisep- 
sis, phenyl  salicylate  is  likewise  the 
most  useful  drug  of  this  group,  hav- 
ing the  added  advantage  of  not  up- 
setting the  stomach.  Diarrhea  due  to 
an  acute  infection  or  toxic  food  is 
frequently  arrested  by  phenyl  salicy- 
late, which  may  be  given  alone  in  5- 
or  yyz-  grain  (0.3  to  0.5  Gm.)  doses  in 
capsules  or  tablets  or  with  2  or  3 
parts  of  bismuth  subnitrate  in  pow- 
ders. Bismuth  subsalicylate  may  be 
substituted  for  the  last-named  com- 
bination, but  its  antiseptic  effect  is 
far  inferior,  ownng  to  the  absence  of 

Local  Uses.  —  In  subacute  and 
chronic  eczema,  salicylic  acid  often 
gives  excellent  results,  more  particu- 
larly in  the  "rubrum"  and  squamous 
varieties,  or  where  there  is  consider- 

able Assuring,  e.g.,  on  the  dorsa  of  the 
liands  and  in  the  flexures  of  the  joints. 
An  ointment  containing  4  to  8  per 
cent,  of  salicylic  acid  in  either  petrola- 
tum, hydrated  wool-fat,  or  zinc-oxide 
ointment  should  be  used  in  such  cases. 
In  eczema  of  the  face,  in  the  weeping 
stage,  or  in  not  too  extensive  ery- 
thematous or  pustular  eczema,  the  fol- 
lowing is  of  value :  Salicylic  acid,  5 
to  10  grains  (0.3  to  0.6  Gm.)  ;  pow- 
dered starch  and  zinc  oxide,  of  each  2 
drams  (8  Gm.)  ;  petrolatum,  ^  ounce 
(15  Gm.). 

In  psoriasis  salicylic  ointments  are 
of  value,  especially  to  remove  the 
scales.  Crocker  recommends  salicy- 
lates internally  in  extensive  but  re- 
cent psoriasis  guttata.  In  pityriasis 
capitis  with  marked  desquamation 
Cantrell  found  useful  a  weak  emul- 
sion of  salicylic  acid  in  water  with 
mucilage  of  acacia.  Pityriasis  rubra 
also  improved  under  mild  salicylic 
ointments,  and  mild  cases  of  ichthyo- 
sis were  likewise  benefited.  Lentigo 
was  usually  cured  by  strong  salicylic 
applications.  Indurated,  papular  acne 
Avas  greatl}^  improved,  and  seborrhea 
of  the  scalp,  chest,  or  nasal  orifices 
favorably  influenced.  Among  the 
other  skin  conditions  in  which  salicy- 
lic acid  has  proven  of  use  are  erythe- 
ma multiforme,  erythema  nodosum, 
lupus  erythematosus,  and  miliaria. 
Erythema  following  horseback  riding, 
or  intertrigo,  may  be  relieved  with  a 
2  per  cent,  salicylic  ointment. 

The  itching  of  urticaria  may  be 
allayed  with  a  dusting  powder  com- 
posed of  salicylic  acid,  1  part;  zinc 
oxide,  3  parts,  and  powdered  starch, 
6  parts.  In  chronic  urticaria,  the  in- 
ternal use  of  20-grain  (1.3  Gm.)  doses 
of  sodium  salicylate  is  also  recom- 
mended.    For  pruritus   of  the  vulva 


and  anus  the  following'  may  be  used :  any  part  of  the  growth  remains,  the 
Salicylic  acid,  white  wax,  of  each  2  treatment  may  be  resumed  and  con- 
drams  (8  Gm.)  ;  cacao  butter,  5  drams  tinned  for  three  days.    This,  however, 
{20    Gm.)  ;   oil   of   nutmeg,    3^    dram  is  not  often  necessary. 
(2  CO.).  Soft    chancres    and    venereal    sores 

In    ordinary   ringworm    (tinea    cir-  may   be   dressed   with    the    following 

cinata)    a   solution   of   10  grains    (0.6  ointment :     Salicylic    acid,    20    grains 

Gm.)  of  salicylic  acid  in  ^^  ounce  (15  (1.3  Gm.)  ;  alcohol,  45  minims  (3  c.c.)  ; 

Gm.)  of  collodion  is  rapidly  curative  benzoinated'  lard,  2  ounces  (60  Gm.). 

where  the  condition  is  not  too  long  As  a  dusting  powder,   1   part  of  the 

standing.  acid  may  be  mixed   with  8  parts  of 

In  hyperidrosis  of  the  feet,  hands,  powdered  starch  or  chalk, 
or  axillae,  a  mixture  of  equal  parts  of  A  1 :  1000  solution  of  salicylic  acid 
powdered   salicylic   acid   and    talc   or  has  been  employed  as  a  nasal  douche 
starch  will  remove  odor  and  tend  to  in  chronic  ozena.     In  chronic  middle- 
arrest  the  trouble.  ear  suppuration  Foltz  has  used  with 

Where  there  is  a  tendency  to  occlu-  satisfaction  insufflations  of  1  part  of 

sion  of  the  ducts  of  sweat-glands  or  powdered  salicylic  acid  with  6  parts 

other    follicles,    mild     salicylic    oint-  of  boric  acid. 

ments  are  of  value  to  prevent  or  over-  Thiersch's     solution,     a     non-toxic 

come  blockage.  fluid  available   for  general   antiseptic 

For  corns,  a  saturated  solution  of  purposes,  consists  of  salicylic  acid,  1 

salicylic  acid  in  collodion,  the  creosote  part ;  boric  acid,  6  parts ;  dissolved  in 

salicylic  plaster  mull  of  Unna   (6  to  water,  500  parts. 

10  parts  of  the  acid  and  1   to  2  parts  Application   of   dry   powdered   sali- 

of  creosote  spread  upon  gutta-percha),  cylic  acid  to  suppurating  and  infected 

or  the  following  combination,  may  be  wounds  gives  excellent  results,  caus- 

relied     on     to     produce     the     desired  '"^    liquefaction    and    prompt    disap- 

pearance  of  the  scab  or  slough,  leav- 

SO    enmg.  ^^^    ^    clean,     bright-red,     granulating 

IJ  Acidi  salicylici   gr.  x  (0.6  Gm.).  surface   which   heals   rapidly.      Offen- 

Olei  terebinthincE  rec-  sive  odors  disappear  within  24  hours. 

tificati rn,v  (0.3  c.c).  It  causes  no  pain  or  irritation.    Doses 

Acidi  acetici  glacialis  ni.ij   (0.12  c.c).  of  3   to  5   gains    (0.2   to  0.3   Gm.)    in 

Cocaina-      hydrochlo-  milk    or    bismuth    suspension    give    fa-) 

ridi   gr.  ij   (0.12  Gm.).  vorable  results  in  typhoid  fever.     In 

Collodii   TTi^c   (6  c.c).  vitro,  0.2  to  0.5  per  cent,   of   the  acid 

M.    Sig. :    Apply  locally.  inhibits  or  destroys  Shiga's  dysentery 

T-                        ,      r                    •      -1  bacillus,     the     B.     typhosus,     staphylo- 

l^or  removal  of  warts,  smular  prep-  ct    ,.*                 ^                  u 

'                  ^     ^  coccus,      streptococcus     pyogenes,      B. 

arations  are  advantageously  used.     A  diphtheria,  pneumococcus,  and  B.  tet- 

mixture    of    salicylic    acid    and    lactic  ani.      A.    Wilson    (Brit.    Med.    Jour., 

acid,  of  each   yi   dram   (2  Gm.)   in  1  Feb.  20,  1915). 

fluidounce  (30  c.c.)   of  flexible  collo-  ^-  E.  de  M.  Sajous 

dion  may  be  applied  to  the  summit  ^               ^^^ 

of  the  wart  with  a  match-stick  night  ^-  ^-  ^^  ^-  Sajous, 

J                •          r         r                   -J  *                               Philadelphia, 
and    mornmg    for    hve    or    six    days. 

Soaking  the  part  in  water  will  then  SALINE  INFUSION.     See  Infu- 

cause  detachment  of  the  slough.     If  signs   Saline. 



(DRY  MOUTH).— Symptoms.— 
Arrest  of  the  salivary  or  l^uccal  secre- 
tions was  first  studied  l)y  Hutchin- 
son, in  1887.  Since  then  about  40 
cases  have  been  recorded.  The 
tongue  appears  red,  devoid  of  epi- 
tlielium,  cracked,  and  absolutely  dry. 
The  inside  of  the  cheek  and  the  hard 
and  soft  palates  are  also  dry,  and 
the  mucous  membrane  is  smooth, 
shining-,  and  pale  (Seifert).  Diminu- 
tion in  the  nasal  and  lachrymal  secre- 
tions has  also  been  noted,  as  well  as 
dryness  of  the  skin  and  crumbling' 
or  falling  out  of  the  teeth.  The 
urine  is  normal.  The  general  health 
and  the  digestion  are  unimpaired, 
but  swallowing  and  articulation  are 
difficult,  owing  to  the  absence  of 
moisture.  The  disease  usually  reaches 
its  greatest  intensity  rapidly,  and 
may  then  remain  without  change  for 
years.  It  usually  persists  until  the 
patient  dies. 

Etiology  and  Pathology. — Xero- 
stomia is  almost  always  met  with  in 
women,  and  about  one-half  of  the 
cases  occur  in  subjects  past  50 
years  of  age.  It  sometimes  follows 
a  shock.  It  is  usually  ascribed  to 
defective  nerve-function,  many  pa- 
tients showing  distinct  evidences  of 
nervous  disturbance:  hysteria,  hypo- 
chondria, anuria,  etc.  In  some  it  ap- 
pears to  result  from  mere  arrest  of 
function  without  impairment  of  the 
general  health.  In  36  cases  studied 
by  A.  J,  Hall  the  state  of  the  salivary 
glands  and  ducts  was  as  follows:  In 
8  cases  the  parotids  were  enlarged, 
either  equally  or  unequally ;  in  3 
they  were  tender  and  painful ;  in  4 
they  were  not  so,  and  in  1  the  gland 
ulcerated  through  into  the  mouth.    In 

5  cases  enlargement  varied  from  time 
to  time;  in  1  of  these  enlargement 
was  most  marked  at  the  menstrual 
period.  With  1  exception,  other 
neighboring  salivary  glands  were 
not  enlarged. 

Treatment. — Pilocarpine  has  been 
used  with  some  success  in  these 
cases,  but  the  condition  usually  re- 
curs. Blackman  employs  the  drug  in 
/JO-  to  i/io-grain  (0.003  to  0.006  Gm.) 
doses,  in  a  gelatin  lamella,  which 
is  placed  on  the  tongue  and  moistened 
with   water. 

PTYALISM. — Excessive  secretion 
of  saliva  occurs  as  a  symptom  of 
rabies,  the  various  forms  of  stomati- 
tis, especially  the  mercurial  form, 
dentition,  various  gastric  disorders, 
etc. ;  but  as  an  idiopathic  disorder  it 
is  rarely  met  with.  It  is  often  ob- 
served in  neurotic  subjects,  especiallv 
children,  and  usually  disappears  after 
a  few  years,  when  the  development 
of  the  subject  has  become  equalized. 
It  occasionally  attends  pregnancy 
{q.  z'.),  and  may  occur  during  men- 
strual periods  and  various  febrile 
disorders,  particularly  smallpox.  The 
effects  of  pilocarpine,  mercury,  iodine, 
copper,  and  other  agents  in  causing 
ptyalism   are   well   known. 

Treatment. — The  general  health 
r-equires  attention,  the  idiopathic  form 
I'cing  in  realitv  a  manifestation  of 
debility.  Weak  astringent  washes, 
or  a  saturated  solution  of  potassium 
chlorate,  may  be  tried.  The  galvanic 
current,  the  positive  pole  being  ap- 
plied in  the  mouth  while  the  latter  is 
full  of  water,  the  negative  pole  being 
placed  over  the  thyroid  cartilage, 
may  prove  of  value  if  used  daily. 

varv  concretions  of  various  sizes 
sometimes  form  in  the  parotid  gland 



and  its  duct, — Stenson's, — causing  in- 
flammation of  the  organ,  retention  of 
saliva,  and  enlargement  of  the  organ. 
The  majority  of  calculi,  however,  are 
found  in  Wharton's  duct:  the  duct 
of  the  maxillary  gland.  Foreign 
bodies — which,  as  shown  by  Desmar- 
tin,  frequently  enter  Wharton's  duct 
— often  act  as  nuclei.  Klebs  and 
Waldeyer  contend  that  masses  of 
micro-organisms  are  the  most  com- 
mon causes  of  salivary  calculi,  the 
phosphates  and  carbonates  of  lime, 
magnesia,  soda,  etc.,  being  deposited 
around  them.  The  stones  may  be- 
come as  large  as  eggs,  and  multiple, 
and  are  occasionally  facetted.  In 
some  cases  the  inflammatory  phe- 
nomena proceed  to  abscess-formation, 
and,  spontaneous  rupture  taking 
place,  a  salivary  fistula  is  formed. 
In  the  case  of  Stenson's  duct  the 
opening  is  opposite  the  second  molar 
of  the  upper  jaw.  Wharton's  duct 
opens  beneath  the  tongue,  under  the 
frenum.  Both  openings  can  be  pene- 
trated with  a  probe,  or  a  fine  needle 
may  be  inserted  into  the  mass  and 
its   contents   thus  recognized. 

Treatment. — It  is  sometimes  pos- 
sible to  remove  a  small  calculus 
through  the  canal ;  but,  as  a  rule,  it  is 
necessary  to  thoroughly  anesthetize 
the  part  with  cocaine  and  to  remove 
the  mass  by  an  incision  through  the 
oral  tissues. 

GLANDS.— Cysts.— Cystic  dilatation 
of  the  parotid  and  maxillary  glands 
or  of  tlieir  ducts  is  occasionally  ob- 
served, as  a  result  of  a  superficial 
inflammatory  process  or  of  cicatricial 
stenosis  of  the  orifices.  In  a  case 
noted  by  Stubenrauch  the  growth — 
a  parotid  cy<,t — was  found  studded 
with    tubercular    nodules.      Stenson's 

duct  may  become  inflated  with  air 
through  forcible  air-pressure — such 
as  that  accompanying  the  playing  of 
wind-instruments,  glass-blowing,  etc. 
— and  simulate  a  cyst. 

In  many  of  these  cases  it  is  neces- 
sary to  remove  the  sac  wall  after 
evacuating  the  contents  by   incision. 

Tumors  of  the  Parotid. — Tumors 
of  the  parotid  are  often  the  result 
of  implication  of  the  glandular  tis- 
sues in  neoplasms  of  neighboring 
structures.  They  may  arise  in  the 
gland  itself,  however.  Almost  any 
variety  of  growth,  especially  ade- 
noma, fibroma,  chondroma,  myx- 
oma and  the  malignant  varieties — 
sarcoma  and  carcinoma — may  be 

The  removal  of  the  entire  gland 
for  large  malignant  growths  necessi- 
tates a  grave  operation,  owing  to 
the  proximity  and  frequent  involve- 
ment of  the  external  carotid,  the  in- 
ternal jugtflar  vein,  and  other  im- 
portant vascular  and  nervous  struc- 
tures. For  this  reason,  large  malig- 
nant neoplasms  are  removed  with 
difficulty  and  often  imperfectly.  Arr 
old  and  good  rule  in  such  cases  is  to 
remove  movable  growths:  i.e.,  those 
which  are  not  firmly  fixed  to  the  un- 
derlying tissues.  Benign  tumors  can 
usually  be  successfully  extirpated. 
After  the  first  free  incision  is  made 
the  mass  should  as  much  as  possible 
be  removed  by  the  fingers.  The 
facial  nerve  and  the  temporomaxillary 
are  thus  less  exposed  to  injury. 

Tumors  of  the  Maxillary  Gland. — 
This  gland  may  be  the  seat  of  any 
of  the  forms  of  tumor  met  in  the 
parotid,  but,  like  it,  is  often  involved 
in  growths  that  develop  in  the  neigh- 
boring structures,  especially  carci- 
noma of  the  inferior  maxillary.     The 



mass  usually  projects  beneath  the 
jaw.  The  removal  is  not  as  difficult 
as  is  the  case  of  tumors  of  the  parotid, 
the  facial  and  ling-ual  arteries,  which 
are  easily  tied,  and  the  ling-ual  and 
hypog-lossal  nerves,  which  can  easily 
l>e  avoided,  offering-  no  obstacle  to  a 
thoroug-h  operation.  Here,  also,  how- 
ever, it  is  always  best  to  use  the  fin- 
eers  to  decorticate,  as  it  were,  the 
g-rowth  after  incision  of  the  superficial 

PAROTITIS. — Inflammation  of  the 
parotid  gland. 

Definition. — Parotitis  is  usually  an 
infectious  disease  {infectious  paro- 
titis), but  it  may  result  from  injury 
{traumatic  parotitis)  or  from  the  ex- 
tension of  inflammatory  or  malig^nant 
.processes  in  adjacent  tissues  {irrita- 
tive parotitis). 

mation of  the  parotid  gland  may  cer- 
tainly result  from  injuries  of  suf- 
ficient severity  to  cause  an  effusion 
of  blood  into  the  gland  or  the  tis- 
sues surrounding  it.  It  may  also  re- 
sult from  burns  or  the  application 
of  caustics.  While  micro-organisms 
may  take  part  in  the  process,  the 
condition  is  quite  different  from  in- 
fectious or  septic  parotitis.  Unless 
infected  with  septic  germs,  suppura- 
tion is  not  common. 

forms  of  parotitis  occur  as  the  direct 
result  of  germ  invasion:    1.  Mumps; 
epidemic  parotitis.  2.  Metastatic,  symp- 
tomatic, suppurative,  or  septic  parotitis. 
The    writers    observed    38    cases    in 
which    extreme    swelling    and    pain    in 
one  or  both  parotid   glands  had  fol- 
lowed typhus  or  relapsing  fever  at  a 
French  hospital  in  Roumania  in  1917. 
The    parotitis     seemed    to    be    more 
common    after   typhus,   and   gangrene 
from    arteritis    after    relapsing    fever. 

but  these  complications  occurred  in 
some  of  both.  They  recall  that  it  is 
due  to  secondary  infection,  strepto- 
cocci predominating.  Bonnet  and  de 
Nabias  (Lyon  Chir.,  Mar.-Apr.,  1919). 

1.  Mumps. — Mumps    is    an    acute, 
infectious,     contagious    inflammation 
of    one    or    both    parotid    glands,    or 
other  salivary  glands,  usually  occur- 
ring epidemically.     Although  inflam- 
mation of  the  parotid  glands  may  be 
caused  by  various  germs,  the  disease 
commonly    known    as    mumps    gives 
every   indication   of  being   a   specific 
^disease.     A  period  of  incubation,  the 
method  of  invasion,  and  the  definite 
course  pursued  mark  the  disease  as 
a    specific   fever.      No    specific    germ, 
however,  has  as  yet  been  discovered. 
Several    micro-organisms    have    been 
isolated   and  held  by  their  discover- 
ers to  be  the  causative  germ  of  the 
disease.      The    last    of    these    at    the 
present    writing   was    a    micrococcus 
described    by    Merelli,    of    Pisa,    to 
which  he  g'ave  the  name  of  Micrococ- 
cus tragcnus.    The  correctness  of  this 
view  has  not  yet  been  confirmed  by 
other  observers. 

In  1908  Granata  concluded  that  the 
virus  of  mumps  may  be  of  the  filter- 
able type.  •  However,  neither  he  nor 
Nicolle  and  Conseil,  who  injected 
bacteria-free  fluid  from  the  parotids 
in  cases  of  human  parotitis,  repro- 
duced the  disease  satisfactorily. 

The  writer  succeeded  in  reproduc- 
ing the  chief  organic  lesions  of  paro- 
titis in  animals  by  means  of  filtered  ex- 
tracts of  saliva  from  human  patients. 
The  active  agent  in  the  infectious 
saliva  was  found  to  be  neutralized  by 
the  serum  of  an  animal  that  had  sur- 
vived the  injection  of  testicular  and 
parotid  emulsions,  while  the  serum 
of  a  normal  animal  had  no  such 
power.  Various  facts  suggested  the 
presence  of  a  minute  filterable  virus. 
Martha  Wollstcin  (Jour.  Exper.  Med., 
xxxiii.  353,  1916). 



In  S  cases  of  mumps  a  Gram  posi- 
tive diplococcus  was  isolated  from  the 
spinal  fluid,  the  blood,  and  a  lymph 
gland  by  the  writer.  The  injection  of 
the  organism  into  the  testicle  of  a 
rabbit  produced  severe  orchitis  in  10 
days.  These  findings  confirm  the 
earlier  reports  of  similar  organisms 
from  cases  of  mumps,  and  it  appears 
probable  that  mumps  is  caused  by  a 
Gram  positive  diplococcus  and  not 
by  a  filterable  virus.  R.  L.  Haden 
(Amer.  Jour.  Med.  Sci.,  November, 

Incubation. — The  period  of  incu- 
bation is  exceedingly  variable.  That 
most  commonly  observed  probably 
lies  between,  16  and  20  days.  It  has 
been  given  by  different  authorities  as 
follows:     Flint,  10  to  18  days;  Holt, 

17  to  20  days;  Ashby  and  Wright, 
14  to  21  days;  Smith,  19  to  21  days; 
Jacobi,  2  to  3  weeks;  Dukes,  16 
to  20  days;  Dauchez,  15  days;  Roth, 

18  days;  Henoch,  14  days. 
Symptoms. — Premonitory  symp- 
toms are  usually  slight  or  entirely 
wanting.  In  rare  cases  malaise  and 
headache  precede  the  actual  onset  for 
a  week.  There  is  frequently  a  period 
of  invasion  lasting  from  twelve  to 
twenty-four  hours,  marked  by  fever- 
ishness,  headache,  muscular  pains, 
anorexia,  and  perhaps  vomiting.  In 
very  many  cases  the  local  symptoms 
are  the  first  to  appear.  Pain  is  usu- 
ally the  first  of  these.  It  is  stitch- 
like in  character  and  is  located  in 
the  parotid  gland,  but  radiates  into 
the  ear.  It  is  increased  by  pressure 
and  by  all  movements  of  the  jaw.  It 
increases  in  severity  and  in  many 
cases  becomes  very  intense.  In  other 
cases  spontaneous  pain  is  not  felt,  it 
being  developed  only  upon  pressure 
or  movements  of  the  jaw.  Rilliet  de- 
scribes three  painful  points :  one  at 
the  level  of  the  temporomaxillary  ar- 

ticulatiorv;  one  below  the  mastoid 
apophysis;  the  third  over  the  sub- 
maxillary gland.  Swelling  soon  en- 
sues, and  first  appears  in  the  depres- 
sion between  the  mastoid  process  and 
the  ramus  of  the  jaw,  forcing  the 
lobe  of  the  ear  outward.  At  first  the 
parotid  gland  alone  is  involved  and 
the  swelling  assumes  the  character- 
istic triangular  shape,  the  upper 
angle  being  just  in  front  of  the  ear. 
As  the  surrounding  tissues  become 
involved,  the  triangular  shape  is 
lost.  The  cheeks,  side  of  the  neck, 
and  regions  behind  the  ear  become 
swelled,  the  swelling  in  some  in- 
stances extending  almost  to  the 
shoulder.  The  tumefaction  in  front 
of  the  ear,  however,  remains  as  one 
of  the  distinctive  marks  of  parotitis. 
The  swelled  area  is  often  reddened, 
but  more  commonly  the  skin  is  nor- 
mal in  color  and  appearance.  Over 
the  gland  the  swelling  is  elastic  to 
the  touch,  but  the  surrounding  tis- 
sues are  usually  edematous  and  have 
a  doughy  feeling  and  may  even  pit  on 

The  pharynx  and  tonsils  are  fre- 
quently involved  by  the  edema,  caus- 
ing much  discomfort.  When  the  dis- 
ease is  unilateral,  the  head  is  inclined 
toward  the  affected  side.  When  both 
sides  are  involved,  the  head  is  held 
rigidly  upright,  as  every  movement 
causes  pain.  The  appearance  is  char- 
acteristic and  striking,  and  in  ex- 
treme cases  the  patient  becomes  al- 
most  unrecognizable. 

Both  sides  are  usually  affected  be- 
fore the  attack  runs  its  course.  They 
may  be  attacked  simultaneously,  but 
more  frequently  the  inflammation  oc- 
curs upon  one  side  a  day  or  two  be- 
fore it  appears  on  the  other.  Of  228 
cases   reported   by    Holt,    both    sides 



were  affected  in  215.  The  interval  is 
sometimes  a  week  or  more,  but  more 
commonly  it  is  not  more  than  three 
days.  In  unilateral  mumps  the  left 
side  is  affected  more  frequently  than 
the  right. 

The  swelling-  commonly  reaches  its 
height  on  the  third  day ;  it  remains 
stationary  for  two  or  three  days,  and 
then  subsides  witli  greater  or  less 
rapidity.  The  edema  of  the  sur- 
rounding tissues  is  the  first  to  dis- 
appear. After  the  edema  has  gone 
the  gland  is  sometimes  slow  to  gain 
its  normal  dimensions.  Seven  to  ten 
days  are  required  for  the  disease  to 
run  its  course,  but  the  duration  of  the 
illness  depends  also  upon  the  interval 
between  the  involvement  of  the  two 
sides.  A  patient  of  my  own  was  con- 
fined to  the  house  almost  a  month. 
The  parotid  on  the  right  side  was 
attacked  a  week  after  that  on  the  left, 
and  this  was  followed  by  orchitis  on 
the  eighteenth  day. 

The  other  salivary  glands  are  not 
infrequently  involved,  and  in  rare 
cases  the  submaxillary  glands  alone 
are  affected. 

The  secretion  of  saliva  is  usually 
diminished,  but  occasionally  it  is  in- 
creased. This,  together  with  the 
painful  swelling  of  the  face,  edema  of 
the  throat,  and  constitutional  symp- 
toms, renders  the  patient  extremely 
wretched.  Attempts  to  examine  the 
throat  are  often  futile,  the  patient 
being  scarcely  able  to  open  the  mouth. 
He  will  make  no  attempt  at  masti- 
cation and  refuse  food,  owing  to  the 
pain  during  deglutition.  These  symp- 
toms are  especially  prominent  when 
the  tonsils  are  involved.  Even  speak- 
ing is  then  painful.  Although  the 
swallowing  of  acids  commonly  causes 
severe  pain,  it  does  not  always  do  so, 

and  the  popular  belief  that  it  is  an 
infallible  sign  of  mumps  is  erroneous. 
Constitutional  symptoms  are  usu- 
ally not  severe.  The  fever  is  rarely 
high.  The  temperature  ranges  in 
ordinary  cases  from  100°  to  102°  F. 
(37.8°  to  38.9°  C).  It  frequently  does 
not  go  above  101°  F.  (38.3°  C.)  at  any 
time  during  the  attack,  but  in  severe 
cases  it  may  reach  104°  F.  (40°  C.) 
or  even  more.  Other  symptoms  are 
those  .common  to  all  febrile  condi- 
tions. When  the  swelling  is  extreme, 
pressure  upon  the  vessels  of  the  neck 
may  cause  headache  and  marked 
cerebral  disturbance.  Delirium  is 
sometimes  due  to  this  cause.  The 
severity  of  the  disease  varies  greatly 
in  different  epidemics.  In  some  the 
children  are  but  slightly  ill ;  in  others 
they  are  quite  seriously  so  when  the 
disease  is  at  its  height,  and  are  left 
weak  and  anemic. 

The  blood  in  mumps  shows  defi- 
nite changes  in  the  corpuscular  con- 
tent consisting  (a)  in  a  slight  in- 
crease in  the  total  number  of  leuco- 
cytes, and  (b)  in  a  lymphocytosis 
which  is  both  relative  and  absolute. 
The  lymphocytosis  is  present  on  the 
first  day  of  the  disease  and  persists 
for  at  least  fourteen  days.  The  oc- 
currence of  orchitis  does  not  invari- 
ably alter  the  blood-picture.  The 
blood  changes  are  of  distinct  diag- 
nostic value  in  differentiating  mumps 
from  other  inllammatory  swellings 
of  the  parotid  or  submaxillary  sali- 
vary glands  and  from  cases  of 
lymphadenitis.  A  lymphocytosis  of 
the  cerebrospinal  fluid  occurs  when 
mumps  is  complicated  by  meningitis 
or  by  lesions  affecting  the  cranial 
nerves.  It  has,  however,  also  been 
found  in  cases  of  mumps  which  have 
presented  no  clear  clinical  symptoms 
of  any  organic  lesion  of  the  nervous 
system.  From  a  consideration  of  the 
blood  and  cerebrospinal  fluid,  one  is 
justified    in    assuming   that   the   virus 



of  mumps  excites  an  inflammatory 
reaction,  the  characteristic  feature  of 
which  is  a  great  aggregation  of 
lymphocytes.  A.  Failing  '^Lancet, 
July  12,  1913). 

Diagnosis. — The  rapid  onset  and 
almost  equally  rapid  subsidence  of 
the  glandular  enlargement  is  a  most 
characteristic  feature  of  mumps. 
This,  together  with  the  location  of 
the  tumor  and  its  peculiar  shape  and 
large  size,  distinguishes  it  from 
acute  enlargement  of  the  lymphatic 
nodes,  as  well  as  chronic  malignant 
growths.  The  location  of  the  tumor 
is  usually  sufficient  to  distinguish  it 
from  the  cervical  swellings  of  scarlet 
fever  and  diphtheria,  but  examina- 
tion of  the  throat  should  always  be 
made  in  cases  in  which  there  is  the 
slightest  doubt. 

Etiology.  —  Although  mumps  is 
spread  by  contagion,  susceptibility  is 
probably  less  than  to  any  of  the 
other  contagious  diseases.  Close 
contact  is  usually  necessary.  The 
disease  is  rarely  carried  from  one 
person  to  another  by  a  third,  but  that 
is  known  to  have  occurred.  The  dis- 
ease is  rare  under  4  years  and  very 
few  cases  in  infants  have  ever  been 
reported.  It  is  rare  in  adult  life  and 
still  more  so  in  old  age.  It  is  most 
common  between  the  ages  of  5 
and  14. 

The  exact  period  of  infection  is 
doubtful.  Contagion  is  possible  from 
the  first  symptoms  or  even  before  the 
swelling  of  the  glands  has  appeared. 
The  power  of  infection  seems  to  con- 
tinue in  some  cases  for  several  days 
after  the  first  symptoms  have  disap- 

Epidemics  of  mumps  occur  more 
commonly  in  the  fall  and  spring  than 
at  any  other  season.  They  vary 
greatly  in  frequency  of  occurrence 
and  the  extent  of  territory  involved, 
occurring  in  some  localities  almost 
annually  and  in  others  only  at  inter- 
vals of  many  years.  The  infective 
power  of  the  disease  varies  decidedly 
in  dififerent  epidemics.  Epidemics  of 
measles  and  mumps  are  frequently 

Recurrence  of  mumps  is  uncom- 
mon, but  is  not  unknown,  as  my  own 
personal  experience  has  positively 

Pathology. — Opportunity  for  post- 
mortem study  of  parotitis  is  so  rare 
that  its  pathology  is  not  yet  fully  un- 
derstood. So  far  as  known,  patho- 
logical changes  are  confined  to  the 
salivary  glands.  Infection  probably 
takes  place  through  the  salivary 
ducts,  the  gland-substance  being  first 
involved.  The  periglandular  tissue 
is  involved  secondarily.  In  those 
cases  in  which  pathological  exami- 
nations have  been  made,  the  salivary 
ducts  have  been  found  to  be  occluded 
by  swelling  and  inflammation  of 
their  walls.  The  gland  itself  is 
hyperemic  and  edematous.  Suppu- 
ration is  rare  and  probably  does  not 
occur  in  simple  parotitis.  Its  occa- 
sional occurrence  is  probably  due  to 
pyogenic  bacteria  which  have  found 
admission  with  the  specific  germs. 

Complications  and  Sequels. 
— Among  young  children  complica- 
tions are  rare.  Suppuration  occurs  in 
about  1  per  cent,  of  the  cases,  accord- 

peared.      Isolation,    to    be    effective,  ing  to    Holt,   and    is   usually    due   to 

must  be  continued  for  at  least  a  week  some  accidental  infection  by  pyogenic 

after   the   swelling  has   entirely   sub-  germs.      Deafness,   due   not   to   otitis 

sided,  or  nearly  three  weeks  from  the  media,  but  to  disease  of  the  auditory 

first  symptoms.  nerve,   has   been   reported   in   a   very 




few  cases.  It  is  usually  unilateral 
and  permanent.  Facial  paralysis, 
multiple  neuritis,  and  other  nervous 
disorders  also  occur  in  very  rare  in- 
stances, and  nephritis  is  not  unknown 
as  a  sequel.  Meningitis  and  ocular 
complications  have  also  been  ob- 
served. Pancreatitis  with  epigastric 
and  vomiting-  and  glycosuria  are  not 
uncommon  complications. 

The  writer  has  seen  many  cases 
of  epigastric  pain  with  vomiting  in 
the  last  stages  of  mumps.  Out  of  20 
cases  in  one  school,  10  followed  this 
course,  and  all  showed  tenderness  to 
pressure  over  the  pancreas.  Fox  re- 
ports a  similar  case:  On  the  fifth  day 
of  mumps  a  boy  developed  fever, 
epigastric  pain,  and  vomiting,  and  a 
deep-seated  swelling  was  felt  in  the 
epigastric  region.  There  was  no 
sugar  in  the  urine,  and  the  boy  re- 
covered. Cecil  Reynolds  (Brit.  Med. 
Jour.,  ii,  352,  1910). 

Pancreatitis  may  be  one  or  the  sole 
manifestation  of  the  acute  infection 
called  epidemic  parotitis.  The  pain 
and  protrusion  of  the  stomach  region 
which  some  writers  have  explained 
as  acute  mumps  pancreatitis  may 
have  been  merely  an  acute  gastritis 
as  a  manifestation  of  the  infectious 
process.  L.  Cheinisse  (Semaine  med., 
Feb.  21,  1912). 

In  the  pancreatitis  of  mumps,  pain 
is  the  most  noteworthy  symptom; 
tenderness  in  the  region  may  persist 
after  other  symptoms  have  disap- 
peared. Constipation,  followed  by  a 
colliquative  diarrhea,  is  common. 
Fever,  epistaxis,  profuse  sweating, 
irregular  pulse,  and  the  facies  of 
grippe  are  also  noted.  Jaundice  may 
supervene.  The  diagnosis,  in  view 
of  the  very  obvious  mumps,  is  there- 
fore not  difficult.  The  prognosis  is 
favora1)le.  Raymond  (Paris  med., 
Aug.  3,  1912). 

A  most  peculiar  but  characteristic 
complication  is  orchitis.  It  is  most 
common    in    adolescents    and    adults 

and  is  extremely  rare  ia  children. 
Among  230  cases  of  mumps  Rilliet 
and  Barthez  saw  but  10  cases  of 
orchitis,  only  1  being  under  12  years. 
Its  frequency  undoubtedly  varies 
in  different  epidemics.  The  disease 
is  a  true  orchitis,  but  epididymitis 
in  rare  cases  occurs  either  alone  or 
complicating  the  orchitis.  The  dis- 
ease is,  as  a  rule,  unilateral,  and  oc- 
curs usually  between  the  eighth  and 
sixteenth  day  of  the  mumps.  A  chill 
at  the  onset  is  not  uncommon,  and 
more  or  less  fever  is  an  accompani- 
ment. The  acute  symptoms  increase 
somewhat  slowly  during  a  period  of 
three  to  six  davs,  when  thev  subside 
and  the  swelling  rapidly  diminishes. 
So  rapid,  in  fact,  is  the  return  to  nor- 
mal conditions  that  it  is  clear  that 
the  inflammation  does  not  go  beyond 
the  stage  of  serous  exudation.  In  bi- 
lateral orchitis  one  side  precedes  the 
other,  as  a  rule,  by  one  or  two  days. 
In  many  cases,  as  the  orchitis  de- 
velops the  parotitis  subsides,  which 
has  given  rise  to  the  theory  of  me- 

The  writer  has  had  7  cases  of  par- 
tial or  complete  (so  complete  that  not 
a  vestige  of  prostatic  tissue  could  be 
made  out)  atrophy  of  the  prostate, 
in  which  an  antecedent  parotiditis 
seemed  to  j^e  the  sole  etiological  fac- 
tor; in  some  of  these  cases  (5)  the 
atrophy  was  accompanied  by  atrophy 
of  the  testicles;  in  2  the  testicles 
seemed  to  be  unaffected.  W.  J.  Rob- 
inson (Letter  to  the  N.  Y.  Med.  Jour., 
Mar.  6,  1915). 

In  a  series  of  115  cases,  epididy- 
mitis was  met  by  the  writer  in  20  in- 
stances, in  18  of  which  it  was  inde- 
pendent of  orchitis.  It  began  about 
the  sixth  day  of  the  disease  and  lasted 
fifteen  to  twenty  days.  In  half  the 
cases  it  was  accompanied  by  distinct 
swelling  of  the  organ,  which  in  the 
remaining  instances  was  merely  ten- 


der.     Inflammation  of  the  vas   defer-  male  patients  developed  orchitis  and 

ens  was  noted  in  40  cases,  generally  5.3  per  cent,  of  the  women  had  mas- 

independently   of  epididymitis   or   or-  titis;  that  is,  about  half  of  the  women 

chitis.      It    began    on    the    second    or  who  were  nursing  infants  at  the  time. 

third  day  of  the  disease,  and  was  bi-  Bertelsen  (Ugeskrift  for  Laeger,  Dec. 

.    lateral    in    26    cases.      Twenty-three  9,   1915). 

cases    showed    prostatitis.      Enlarge-  ^^  ^„*._„„^         n                  r            j- 

r    ,     ,        ,        ,        re          '  Treatment.  —  Cases      of      ordinary 

ment  of  the  lymph-nodes  of  Scarpa  s  .                                                                   ■' 

triangle  was  met  with  in  10  cases,  and  seventy  require  but  little  medication, 

of  those  of  the  iliac  chain  in  6  cases.  A  mild  antiseptic  mouth-wash  should 

Swelling  of  the  tonsils  took  place  in  be  given  with  a  view  of  preventing 

40  cases.    Diarrhea  was  noted  for  two  infection  by  pyogenic  bacteria.     The 

or  three  days  in  60  cases.     In  2  cases  ^.^^    ^^^^^^j^    ^^^    j.       j^    ^^^^    ^^^    ^^^^^ 

appendicitis    suddenly    developed    on  ,  ,  ,      ,           •     ,      ,  -r    i           •     r 

the  tenth  day;  recovery  in  two  weeks  should  be  kept  in  bed  if  there  IS  fever, 

took    place    in    both    instances    under  Warm    camphorated    oil    is    the   most 

rest,  dieting,  and  local  application  of  soothing  application  that  can  be  used 

ice.      Ramond    and    Goubert    (Presse  locally. 

med.,  Mar.  25,  1915).  ^N\,^x^  there  is  considerable  tension 
In  females  inflammation  of  the  or  throbbing,  the  ice-bag  sometimes 
breast  or  ovaries  occurs  in  very  rare  gives  more  relief  than  warm  appli- 
instances.  The  number  of  well-  cations.  In  general  terms,  the  treat- 
authenticated  cases  of  this  complica-  ment  is  the  same  as  for  other  febrile 
tion,  it  must  be   said,   is  very  small,  conditions. 

Involvement  of  the  thyroid  gland  and  Buccal     antisepsis,      according     to 

of     the     lymphatic     nodes     has     been  Martin,    diminishes    the    chances    of 

observed  testicular    complications    in    parotitis. 

_,'.,,                  .                 ,  A  4  per  cent,   solution  of  boric  acid 

Prognosis.-Mumps     is     rarely     a  ^^^^^  ^^^^^  ^^^^^^^  ^^  ^^.bolic  acid 

serious   disease.      It   usually   runs   an  should  be  employed  as  a  gargle,  and 

uneventful     course,     and     under      12  pilocarpine    subcutaneously    in    doses 

years     complications     are     rare.       In  of  %  grain  (0.01  Gm.)  once  daily,  to 

children    of    the    so-called    scrofulous  diminish  the  pain  and  lower  the  tem- 

1    ^.          .                    .               .  perature   in   cases   of   orchitis, 

type    resolution    is    sometimes    slow  ^  ^,      .  ,,      . 

■'  ^  The   following  ointment  is    recom- 

and  imperfect.     Among  24,635   cases  mended  by  Tranchet:— 

occurring    in    the    army    during    the  ^  idithyol, 

Civil   War   there   were   39   deaths:   a  iodide   of  lead,  of 

mortality     so     high     as     to     lead    to  each 45  gr.  (3  Gm.). 

doubt  regarding  the  accuracy  of  the  Chloride  of  Ammo- 

statistics.  "*'«"*  ^^  s^-  (2  Gm.). 

„   . ,       .  .  .  Lard    1  oz.  (31  Gm.). 

tpidemic  parotitis  was  never  en- 
countered in  Greenland  until  the  in-  This  ointment  is  to  be  applied  to 
fection  was  brought  in  1913  by  a  ship  the  swelled  parts  three  times  a  day. 
from  Denmark,  and  of  the  2425  in-  In  some  instances  vaselin  may  be 
dividuals  in  the  district,  about  1500  used  in  place  of  the  lard,  and  some- 
contracted  the  disease.  In  the  times  belladonna  may  be  added  with 
writer's    special    district,    191    of    the  advantage. 

285  individuals  were  affected,  that  is,  Where    fever    and    severe   pain    are 

66  per  cent,  of  the  men   and  68  per  present,  sodium  salicylate  is  effective, 

cent,  oi  the  women.     No  infant  under  It     should     be     combined     with     an 

2  was    affected;    18   per   cent,    of  the  alkali: — 



R  Sadii  salicylat., 

Sodii  bicarb aa  gr.  v  (0.3  Gm.). 

Bcnzosnlphinid    q.  s. 

Aqua q.  s.  ad  fjss  (15  c.c). 

Sig. :  Ever}'  two  or  four  hours. 

Stark   (Practitioner,  Mar.,   1911). 

The  application  every  morning  of 
pure  tincture  of  iodine  to  the  pharyn.x 
and  buccal  mucous  membrane,  with 
special  attention  to  the  gingival  fold 
and  opening  of  Steno's  duct,  is  recom- 
mended as  a  prophylactic  by  the 
writer  from  experience  in  military 
barracks.  A  tablet  of  potassium 
chlorate  should  also  be  kept  con- 
stantly in  the  mouth.  Petrilli  (Poli- 
clinico,  June  1,   1913). 

The  writer  tried  convalescent 
serum  in  several  cases,  using  5  c.c. 
for  both  subcutaneous  and  intraven- 
ous injections.  Very  little  reaction, 
lessening  of  pain,  and  earlier  sub- 
sidence of  swelling  and  of  tempera- 
ture were  noted.  Gradwohl  (U.  S. 
Naval  Med.   Bull.,   Oct.,   1919). 

2.  Metastatic  or  Symptomatic  Par- 
otitis.— This  is  an  inflammation  of  the 
parotid  gland  occurring  as  a  result  of 
septic  infection  through  the  blood  or 
through  the  buccal  secretions,  in  the 
course  of  various  affections,  and  often 
ending  in  ulceration.  It  may  be 
acute  or  chronic.  It  is  oftenest  met 
with  in  typhoid,  typhus,  and  scarlet 
fevers,  cholera,  dysentery,  plague, 
pyemia,  pneumonia,  influenza,  puer- 
peral fever,  erysipelas,  and  other  in- 
fectious disorders.  It  may  result, 
also,  from  poisoning  by  mercury, 
lead,  and  the  iodides.  Inflammation 
of  the  testicles  is  another  cause,  espe- 
cially when  the  process  is  gonorrheal. 
Injuries  of  the  alimentary  canal  and 
of  the  testicle  or  pelvic  organs  may 
also  give  rise  to  it.  Parotitis  may 
follow  abdominal  operations,  espe- 
cially ovariotomy,  hysterectomy,  and 
laparotomy  for  peritonitis.  It  has 
also  been  observed  in  cases  of  neu- 
ritis, facial  paralysis,  and  diabetes. 

Symptoms. — When  acute  the  gland 
rapidly  swells.  The  tem])erature 
rises  to  103°  or  104°  F.  (39.4°  or 
40°  C).  The  whole  face  becomes 
enlarged,  when  both  glands  are  in- 
volved, and  the  lids  edematous.  The 
pain  is  sometimes  very  severe,  owing 
to  the  tense  capsule  with  which  the 
gland  is  surrounded.  Pus-formation 
promptly  follows  in  the  majority  of 
cases,  and  the  pus  may  burrow  in 
various  directions, — the  auditory  me- 
atus, the  thoracic  cellular  tissue,  the 
retropharyngeal  tissues,  the  maxillary 
joints,  etc., — and  cause  serious  lesions 
if  not  promptly  evacuated  by  incision. 

Parotitis  was  encountered  by  the 
writer  in  16  of  the  760  cases  of  ty- 
phoid fever  in  his  service.  Several 
of  the  men  died.  The  typhoid  was 
always  unusually  severe  in  these 
parotitis  cases.  Cahanescu  (Wiener 
klin.  Woch.,  May  27,  1915). 

Case  of  suppurative  parotiditis  fol- 
lowing pneumonia  in  a  boy  of  3  years. 
Five  days  later  the  temperature, 
which  had  been  in  the  neighborhood 
of  99.5°  F.  (37.5°  C).  reached  104°  F. 
(40°  C).  No  signs  in  the  chest  were 
demonstrable,  but  on  the  following 
day  a  hard,  tender  swelling  appeared 
in  the  right  parotid  region.  Three 
days  later  a  deep  incision  below  the 
right  ear  reached  an  abscess  and  a 
small  amount  of  pus  was  removed. 
The  smear  showed  pneumococci  and 
a  few  staphylococci.  The  tempera- 
ture fell  and  the  recovery  was  un- 
eventful. J.  P.  Parkinson  (Brit.  Jour, 
of  Children's  Dis.,  May,   1915). 

In  the  chronic  form — which  may 
result  from  mumps,  neighboring  in- 
flammatory processes,  syphilis,  the 
excessive  use  of  mercury,  etc. — the 
gland  is  also  enlarged,  but  less  pain- 
ful, and  may  remain  so  several  years. 

Pathology. — The  process  is  a  sup- 
purative one.  The  pus  may  dis- 
charge through  the  cheek  or  through 



the  external  auditory  meatus,  and 
more  rarely  into  the  mouth,  esopha- 
gus, or  anterior  mediastinum.  The 
abscess  may  be  confined  to  the  paro- 
tid g-land  and  its  immediate  surround- 
ing- tissues  or  it  may  be  so  large  as 
to  involve  the  muscles  and  other  soft 
tissues,  and  even  the  periosteum  of 
the  bones.  The  middle  ear  is  not  in- 
frequently involved,  as  well  as  the 
central  meninges.  Thrombosis  of 
the  jugular  and  other  veins  some- 
times leads  to  septicemia.  In  rare 
instances  the  process  terminates  in 

Prognosis.  —  The  result  depends 
largely  upon  the  condition  of  the  pa- 
tient at  the  time  of  the  onset  of  the 
parotitis.  If  much  reduced  by  the 
primary  disease,  the  complication 
often  precipitates  a  fatal  result.  If 
it  occurs  during  convalescence  and 
the  patient  is  not  already  reduced,  a 
favorable  result  may  be  expected.  In 
other  words,  suppurative  parotitis  in 
itself  is  not  usually  fatal.  Induration 
and  enlargement  of  the  glands  is  a 
common  result. 

Treatment. — By  introducing  a  probe 
into  Stenson's  duct  at  the  first  ap- 
pearance of  swelling,  and  making 
pressure  from  the  outside,  a  small 
quantity  of  pus  may  sometimes  be 
evacuated  and  general  suppuration 
.prevented.  If  this  fails,  poultices 
should  be  applied  to  hasten  suppu- 
ration. An  incision  should  be  made, 
with  antiseptic  precautions,  as  soon 
as  fluctuation  can  be  detected.  The 
treatment  throughout  should  be  that 
appropriate  for  any  acute  abscess. 
Floyd  M.  Crandall, 

New  York, 


H.  Brooker  Mills, 


SALOL.      See  Salicylic  Acid. 

SALOPHEN.-Salophen  (acetyl- 
paramido-phenol  salicylate)  contains  50.9 
per  cent,  salicylic  acid.  It  occurs  in  fine, 
white,  odorless  and  tasteless  scales;  solu- 
ble in  alcohol,  ether,  alkalies,  and  hot 
water,  and  nearly  insoluble  in  cold  water. 
It  is  not  official. 

Salophen  was  introduced  as  a  substi- 
tute for  salicylic  acid  and  salol  by  P. 
Guttmann  (Berl.  klin.  Woch.,  No.  52, 
'91).  It  is  said  to  be  less  poisonous  than 
salol  or  salicylic  acid,  because  the  phenol 
of  the  latter  remedies  is  replaced  by  an 
innocuous   compound   of   phenol. 

TION.—Salophen,  like  salol,  seems  to 
suffer  no  action  until  it  reaches  the  in- 
testines, when  the  pancreatic  juice  splits 
it  up  into  its  component  parts,  salicylic 
acid  and  acetyl-paramido-phenol.  As  the 
latter  appears  innocuous,  the  further  ac- 
tion of  salophen  is  that  of  its  contained 
salicylic  acid.  It  has,  however,  certain 
advantages  over  the  latter  in  that  it  is 
unirritating  and  tasteless  and  is  not  de- 
pressing. It  may  be  given  for  consider- 
able periods  of  time  without  causing 
nausea,  anorexia,  tinnitus,  or  other  un- 
pleasant symptoms.  It  possesses  antisep- 
tic, antipyretic,  and  analgesic  properties, 
and  is  given  in  doses  of  from  5  to  15 
grains  (0.3  to  1  Gm.).  The  maximum  single 
dose  is  given  as  20  grains  (1.3  Gm.);  not 
more  than  90  grains  (6  Gm.)  should  be 
given  during  the  twenty-four  hours. 

THERAPEUTICS.  — The  therapeutics 
of  this  remedy  are  the  same  as  those 
of  salol  and  salicylic  acid.  It  is  given  in 
the  same  cases,  and  in  similar  doses,  and 
is  generally  to  be  preferred  to  either  of 
them,  for  the  reasons  given  above.  It  is 
well  suited,  also,  for  use  in  diseases  of 

Salophen  has  a  most  favorable  influ- 
ence upon  psoriasis,  used  in  10  per  cent, 

Salophen  exerts  an  incontestable  action 
upon  acute  and  subacute  rheumatism, 
but  its  effects  are  less  constant  than  those 
of  salicylic  acid  or  sodium  salicylate. 
In  chronic  and  blennorrhagic  rheumatism 
it  has  not  shown  itself  superior  to  other 




In  chronic  articular  rheumatism  it  is 
no  more  useful  than  the  above-mentioned 
drugs.  It  is  an  excellent  antineuralgic 
and  analgesic  in  cephalalgia,  migraine, 
odontalgia;  facial,  trifacial,  and  intercos- 
tal neuralgia;  am!  in  the  nervous  form 
of  influenza.  It  produces  good  results  in 
chorea.  It  acts  well  in  various  skin  af- 
fections which  are  accompanied  with  itch- 
ing: prurigo,  urticaria,  pruritus  of  dia- 
betes, eczema,  and  psoriasis. 

SALPINGITIS.  See  Ovaries  and 
Fallopian  Tubes,  Diseases  of. 

SALT.     See  Sodium. 

SALVARSAN      See  Dioxydiami- 



OF    SANDALWOOD. -Sandalwood 

(red  saunders;  santaluni  rubrum,  U.  S.  P.) 
is  the  wood  of  Pterocarpiis  santalinns  (nat. 
ord.,  Leguminosse).  It  occurs  in  the  form 
of  raspings,  chips,  or  splinters.  It  con- 
tains a  red  coloring  matter  of  a  resinous 
character,  known  as  santalic  acid,  or  san- 
talin,  which  occurs  in  fine  red,  odorless, 
and  tasteless  needles;  soluble  in  alcohol, 
ether,  in  concentrated  sulphuric  acid,  and 
in  alkalies,  but  insoluble  in  water.  It  is 
used  in  pharmacy  for  imparting  a  red 
color  to  alcoholic  solutions  and  tinctures. 
It  is  the  coloring  principle  of  the  com- 
pound spirit  for  tincture)  of  lavender.  It 
has  no  medicinal  properties. 

Oil  of  sandalwood  (oil  of  santal;  oleum 
santali,  U.  S.  P.)  is  a  volatile  oil  distilled 
from  the  wood  of  Santaluni  aWuin  (nat. 
ord.,  Santalaceje),  indigenous  to  India. 
East  Indian  sandalwood  oil  is  a  rather 
viscid,  yellowish,  or  pale-straw  liquid,  hav- 
ing ah  unpleasant,  resinous,  harsh  taste, 
and  a  faint  but  persistent  aromatic  odor. 
The  chief  constituent  is  an  alcohol  known 
as  santalol. 

DOSE. — Oil  of  sandalwood  is  a  stimulant 
in  small  doses,  and  an  irritant  in  large 
doses,  to  the  various  mucous  membranes. 
It  checks  the  secretions  of  the  mucous 
membranes  and  causes  dryness  of  the 
throat  and  thirst.  S.  Rosenberg  has 
noticed,  after  doses  of  60  drops  a  day, 
irritation  of  the  alimentary  canal,  burning 

in  the  urethra  during  micturition,  and  an 
eruption  of  small  red  prominences  upon 
the  entire  surface  of  the  body,  involving 
even  the  conjunctiva;.  Large  doses  may 
produce  considerable  lumbar  pain. 

Its  general  systemic  action  is  unknown. 
It  is  apparently  more  stimulating  than  oil 
of  eucalyptus,  and  rather  less  than  tere- 
l)ene.  It  is  eliminated  l)y  the  urinary  and 
respiratory  mucous  membranes;  the  odor 
is  sometimes  perceptible  in  the  perspira- 
tion. Unlike  copaiba,  it  causes  no  cuta- 
neous eruptions,  and  is  less  likely  to  pro- 
duce gastric  or  intestinal  disturbance. 
Absorption  and  elimination  are  very 
rapid;  it  may  be  detected  by  its  odor  in 
the  urine  half  an  hour  after  its  ingestion. 
It  may  be  given  in  doses  of  from  5  to  30 
minims  (0.3  to  2  c.c),  in  capsules  or  dis- 
solved in  alcohol  and  flavored  with  cin- 
namon,   in    emulsion,   or  on   sugar. 

THERAPEUTICS.— Oil  of  sandalwood 
is  an  efficient  remedy  in  asthma,  chronic 
bronchitis,  in  the  later  stage  of  acute  bron- 
chitis, and  in  the  subacute  or  chronic  stage 
of  gonorrhea.  It  is  also  used  as  an  in- 
gredient of  perfumes.  It  has  also  been 
used  in  cystitis,  but  care  should  be  taken 
to  avoid  large  doses,  and  thereby  the 
urethral   scalding  pain   they  cause. 

SANGUINARIA.  -Sanguinaria,  or 
blood-root,  is  the  rhizome  of  Sanguinaria 
canadensis  (fani.,  Papaveracese),  a  native  of 
eastern  and  central  North  America.  San- 
guinaria contains  citric  and  malic  acids, 
red  resin,  and  starch,  but  its  important 
constituents  are  its  alkaloids,  at  least 
five  in  number,  of  which  sanguinarine 
and  chclerythrine  are  the  most  important. 

Sanguinaria,  U.  S.  P.  (sanguinaria,  or 
blood-root).  Dose,  1  to  5  grains  (0.06  to 
0.30    Gm.). 

Tinctiira  sanguinaria,  U.  S.  P.  (tincture 
of  sanguinaria).  Dose,  10  to  40  minims 
(0.60  to  2.60  c.c). 

Sanguinarine  (alkaloid).  Dose,  Yxn  to 
y^  grain  (0.004  to  0.008  Gm.). 

Fluidextractum  sanguinarise,  N.  F.  (fluid- 
extract  of  sanguinaria).  Dose,  1  to  5 
minims  (0.06  to  0.30  c.c). 

Syrupus  sanguinaria?,  N.  F.  (syrup  of 
sanguinaria).  Dose,  30  minims  (2  c.c), 
representing  6  grains  (0.4  Gm.)  of  san- 



Syrupus  pini  strobi  comp.,  N.  F.  (com- 
pound syrup  of  white  pine).  Dose,  2 
fluidrams  (8  c.c),  representing  5  grains 
(0.3  Gm.)  each  of  white-pine  bark  and 
wild-cherry  bark,  together  with  small 
quantities  of  aralia,  populus,  sanguinaria, 
sassafras,  cudbear,  glycerin,  alcohol,  and 
a  little  chloroform. 

powder  inhaled  causes  violent  sneezing 
and  free  secretion  of  mucus.  It  is  feebly 
escharotic.  The  taste  is  harsh  and  bitter. 
In  small  doses  sanguinaria  produces  a 
sense  of  warmth  in  the  stomach  and  stim- 
ulates the  secretions.  Moderate  doses 
produce  nausea  and  depression  of  the  cir- 
culation. In  large  doses  it  causes  inflam- 
mation of  the  stomach  with  intense  burn- 
ing, thirst,  vomiting,  dimness  of  vision, 
dilatation  of  the  pupils,  vertigo,  great  pros- 
tration and  muscular  relaxation,  cold  and 
clammy  skin,  and  collapse.  After  a  pre- 
liminary increase  of  arterial  tension  the 
heart  action  becomes  depressed.  The 
spinal  reflexes  are  reduced  and  the  spinal 
centers  paralyzed.  Death  is  often  pre- 
ceded by  convulsions  either  of  spinal 
origin  or  from  carbonic  acid  poisoning 
due  to  failure  of  respiration. 

The  stomach  and  bowels  should  be 
washed  out  with  warm  water.  The  dif- 
fusible stimulants  should  be  administered. 
Digitalis,  amyl  nitrite  and  strychnine 
hypodermically  are  efficient,  with  mor- 
phine and  atropine,  if  necessary,  to  relieve 
pain  or  severe  nausea.  The  patient  should 
be  kept  warm. 

naria is  chiefly  used  as  a  stimulating 
expectorant  in  subacute  and  chronic 


XONIN. — Santonica  (Levant  or  German 
wormseed)  is  the  unexpanded  flower- 
heads  of  Artemisia  pauciflora  (fam.,  Com- 
positse),  a  native  of  Turkestan  and  the 
surrounding  countries.  It  contains  about 
1  per  cent,  of  volatile  oil,  IK'  to  3  per 
cent,  of  santonin  and  a  variable  amount 
of  artemisin.  Since  the  isolation  of  san- 
tonin from  santonica,  the  use  of  the  crude 
drug  has  been  abandoned. 

Santonin  occurs  in  faintly  acid,  shining, 

colorless,  flattened,  rhombic  prismatic 
crystals,  odorless,  and  at  first  nearly 
tasteless,  but  with  a  bitter  after-taste.  It 
is  permanent  in  the  air,  but  turns  yel- 
low on  exposure  to  light.  It  is  soluble 
in  alkalies  and  most  volatile  oils,  in  5300 
parts  of  cold  water,  250  parts  of  boiling 
water,  34  parts  of  alcohol,  78  parts  of 
ether,  and  in  2.5  parts  of  chloroform,  and 
nearly  insoluble  in  glycerin.  Colored 
santonin  is  an  unreliable  remedy. 

Santoiiinuui,  U.  S.  P.  (santonin).  Dose, 
1  to  4  grains  (0.06  to  0.25  Gm.)  for  an 
adult,  ^  to  K  grain  (0.015  to  0.03  Gm.) 
for  a  child. 

Santonica,  U.  S.  P.  VIII  (santonica). 
Dose,  10  to  40  grains  (0.60  to  2.60  Gm.). 

Trochisci  santonini,  N.  F.  (troches  of 
santonin,  worm  lozenges),  each  contain- 
ing K  grain  (0.03  Gm.)  santonin.  Dose,  1 
to  4  troches. 

Trochisci  santonini  compositi,  N.  F.,  con- 
taining santonin  and  calomel,  of  each,  Yz 
grain  (0.03  Gm.). 

Sodium  santoninate,  official  in  the  U.  S. 
Pharmacopoeia  of  1880,  is  a  very  soluble 
salt,  a  fact  which  forbids  its  use  and  that 
of  other  santoninates,  since  the  object  of 
using  this  remedy  is  to  act  locally  upon 
the  parasites.  When  given  for  other  pur- 
poses than  as  a  vermifuge  the  dose  is  5 
to  10  grains  (0.30  to  0.65  Gm.). 

tonin is  decomposed  in  the  blood,  disturb- 
ing the  nutrition  of  the  cerebral  centers, 
and  producing  xanthopsia  or  chromatopsia, 
a  condition  where  objects  appear  yellow, 
red,  green,  or  blue,  either  by  staining  the 
humors  of  the  eye  or  by  its  action  upon 
the  retina  and  perceptive  centers;  the 
urine  is  stained  a  greenish-yellow,  or,  if 
alkaline,  a  reddish-purple  color,  due  to 
xanthopsin,  a  derivative  of  santonin. 
Elimination  is  by  the  kidneys,  is  slow, 
taking  about  two  days  for  the  removal 
of  an  ordinary  dose.  There  is  an  in- 
creased flow  of  urine  and  more  frequent 

often  occurs  l)y  children  eating  freely  of 
worm  lozenges,  or  from  susceptibility  to 
its  action.  Toxic  doses  produce  alarm- 
ing symptoms — muscular  tremors,  vertigo, 
cold    sweats,    mydriasis,    stupor    and    epi- 



leptiform  convulsions.  Death  occurs  from 
respiratory  failure.  A  case  of  urticaria 
occurred  after  a  3-grain  dose  to  a  child, 
and  a  general  niorbilloid  eruption  and  in- 
tense punctiform  rash  on  the  buccal  and 
faucial  mucous  membranes  after  a  5-grain 
dose    taken    by    an    adult. 

Treatment  of  Santonin  Poisoning. — The 
treatnu-nt  consists  of  the  use  of  diffusible 
stimulants,  hot  baths,  demulcent  drinks, 
belladonna  and  strychnine,  with  inhala- 
tions of  ether  to   control   the  convulsions. 

important  use  of  santonin  is  that  of  a 
vermifuge  to  expel  the  roundworm  {As- 
caris  lumbricoidcs  or  the  Oxyiiris  vcr~ 
micuJaris  (thread-  or  seat-  worm)  from 
the  intestines.  It  has  no  efifect  upon  the 
tapeworm.  In  persistent  incontinence  of 
urine  santonin  has  been  efficient  when  all 
other  remedies  have  failed.  It  is  often 
useful  when  the  optic  nerve  is  diseased, 
to  restore  the  activity  of  vision,  and  in 
some  cases  of  color  blindness. 

As  an  anthelmintic  santonin  should  be 
administered  on  an  empty  stomach. 
Whitla  and  Demme  combine  santonin  with 
castor  oil,  but  in  aggravated  cases  the  lat- 
ter preferred  to  give  it  in  a  slightly 
sweetened  oleaginous  solution,  ^  grain 
(0.03  Gm.)  to  1  ounce  (30  c.c.)  of  olive 
oil.  A  previous  saline  purgative  (mag- 
nesia or  rhubarb  and  magnesia)  removes 
the  mucus  in  which  worms  breed.  The 
dose  of  santonin,  given  at  night,  should  be 
followed  by  a  saline  purgative  in  the 
morning,    preferably    before    breakfast. 

Santonin  has  been  recommended  by 
Whitehead,  of  Manchester,  in  amenor- 
rhea, especially  when  due  to  chloranemia. 
He  gives  a  10-grain  (0.6  Gm.)  dose  on 
two  successive  nights.  Cadogan  Master- 
man  has  found  this  method  useful  in 
severe  uterine  colic  arising  from  suppres- 
sion of  the  menses. 

SAPREMIA.  See  Wounds,  Septic. 
SARCOMA.     See  Cancer. 

SARSAPARILLA.— Sarsaparilla   is 

the  dried  root  of  Smilax  vicdica,  Sinilax 
ornata,  Smilax  papyracccc,  Smilax  officinalis 
(fam.,  Liliacese),  and  other  varieties  of 
smilax  indigenous  to  central  America, 
Mexico,  Brazil,  Honduras,  and  other  trop- 

ical and  subtropical  American  countries. 
The  roots  are  without  odor  and  have  a 
mucilaginous,  bitter  and  acrid  taste.  Sar- 
saparilla contains  about  3  per  cent,  of 
saponin-like  substance  (separable  into  3 
glucosides),  up  to  15  per  cent,  of  starch, 
a  little  resin,  volatile  oil,  pectin,  calcium 
oxalate,  etc.  The  glucosides  are  the  im- 
portant constituents,  sarsasaponin,  paril- 
lin,  and  smilasaponin,  the  last  two  being 
known    as    smilaciii. 

Sarsaparilla,  U.   S.   P.   (sarsaparilla  root). 

Fluidextractum  sarsaparilla,  U.  S.  P. 
(fluidextract  of  sarsaparilla).  Dose,  J/2  to 
1   dram    (2  to  4  c.c). 

Fluidextractum  sarsaparillcc  compositum, 
U.  S.  P.  (compound  fluidextract  of  sarsa- 
parilla), containing  sarsaparilla,  15  parts; 
licorice,  12  parts;  sassafras  bark,  10  parts; 
mezereum,  3  parts;  glycerin,  10  parts; 
and  diluted  alcohol  to  make  100  parts. 
Dose,  ^  to  1  dram  (2  to  4  c.c). 

Syrupus  sarsaparillce  compositus,  U.  S.  P. 
(compound  syrup  of  sarsaparilla),  con- 
taining fluidextract  of  sarsaparilla  (20 
per  cent.),  fluidextracts  of  licorice  and 
senna  (of  each  1.5  per  cent.),  and  oils 
of  anise,  gaultheria,  and  sassafras  (of  each 
0.02  per  cent.).  Dose,  1  to  4  drams 
(4   to   16  c.c). 

THERAPEUTIC  USES.— Sarsaparilla 
is  probably  inert,  or  nearly  so,  in  the 
dose  usually  given,  though  moderate  doses 
apparently  aid  digestion  and  improve  the 
appetite.  Its  chief  value  is  as  a  pleasant 
vehicle  for  disguising  the  taste  of  the 
iodides  and  of  the  mercurial  salts.  While 
there  is  no  evidence  of  a  curative  action 
of  sarsaparilla  by  itself  in  syphilis,  a  tem- 
porary recourse  to  the  remedy  has  been 
considered  useful,  especially  in  debilitated 
patients  in  whom  mercury  and  the 
iodides  have  seemingly  lost  their  bene- 
ficial action  or  have  been  improperly  ad- 
ministered. Phillips  recommends  this 
remedy  in  chronic  lung  affections  with 
much  wasting;  in  chronic  rheumatism 
and  cutaneous  disorders  with  venereal 
taint.  Sir  Astley  Cooper  advises  its  use 
in  the  cachexia  caused  by  chronic  sup- 
puration, in  chronic  abscesses,  ulcers,  and 
bone  disease.  Zittmann's  decoction  (a  de- 
coction of  sarsaparilla,  calomel,  cinnabar, 
alum,   senna,   licorice,   anise-seed  and  fen- 



nel)  is  much  used  by  the  German 
physicians  in  chronic  rheumatism,  syphiUs, 
and  scrofula.  In  domestic  medicine  sar- 
saparilla  has  been  a  favorite  blood 


flammatory  contagious  disease  of  the 
skin,  due  to  the  presence  of  the  Acarus 
scabici  and  attended  by  severe  pruritus. 
SYMPTOMS.— The  eruption  produced 
by  the  Acarus  scabici  consists  of  scattered 
vesicles  and  papules,  which  are  usually 
located  between  the  fingers  and  on  the 
flexor  side  of  the  wrists  and  elbows. 
The  axillae,  mons  veneris,  abdomen  and 
buttocks,  the  penis,  the  mammse,  and  in 
children  the  legs  and  feet  are  the  points 
of  predilection  next  in  order.  The  bur- 
rows of  the  parasite  resemble  scratches, 
which,  upon  close  examination,  may  be 
seen  to  be  beaded.  The  Acarus  may 
readily  be  extracted  from  its  burrow  with 
the  tip  of  a  needle  for  microscopic  ex- 
amination. The  eruption  is  attended  by 
severe  itching,  which  is  especially  marked 
at  night.  The  scratching  to  which  the 
patient  subjects  the  part  greatly  increases 
the  local  irritation.  The  eruption  may 
become  pustular  or  complicated  by  other 
dermatoses  (eczema,  urticaria,  etc.),  and 
present  various  characteristics  due  to  the 
accumulation  of  epidermic  detritus,  dead 
acari,  etc.,  or  accumulated  crusts.  The 
hairs  of  the  limbs  afifected  are  often  shed, 
and  the  nails  may  become  hypertrophied. 
Schamberg  and  Strickler  found  that  of 
forty-seven  cases  of  scabies,  over  80  per 
cent,  showed  5  or  more  per  cent,  of 
eosinophiles;  the  maximum  was  19  per 
cent.,  and  the  average  7  per  cent,  (the 
normal  maximum  is  4  per  cent.).  The 
incubation  period  extends  from  two  days 
to  a  week.  Occasionally  the  itching  is 
absent — apruriginous  scabies.  During  a 
general  illness  scabies  is  apt  to  disappear 
or  improve;  but  the  disease  reappears  as 
soon  as  convalescence  is  established. 

ETIOLOGY.— The  Acarus  scabici  is  about 
one-quarter  millimeter  long,  and  resem- 
bles an  eight-footed  turtle  in  general  out- 
line; the  males  live  under  the  skin  or  epi- 
dermic scales,  the  females  under  the 
epidermis  in  the  burrows,  where  they  de- 
posit their  eggs.     Acarus  does  not  inhabit 

the  prickly  layer,  but  the  undermost  part 
of  the  middle  layer  of  the  epidermis.  The 
eczema  of  scabies  is  not  caused  by 
scratching,  but  by  irritating  substances 
given  off  by  the  Acarus,  according  to 

While  the  female  mite  is  visible  to  the 
naked  eye,  the  male  is  much  smaller. 
Females  are  more  numerous  than  males, 
and  when  fecundated  penetrate  into  the 
epiderm,  making  a  burrow  in  which  they 
deposit  their  ova,  from  6  or  9  up  to  30  in 
number.  The  mite  cannot  retreat  be- 
cause of  several  bristling  hairs  project- 
ing from  her  body;  she  dies  in  the  bur- 
row; the  eggs  mature  in  a  few  days,  and 
the  resulting  larval  forms  emerge  upon 
the  surface  and  become  sexually  active, 
become  impregnated,  burrow,  deposit  ova 
and  die,  and  thus  the  cycle  continues. 
The  life  of  the  individual  mite  is  from  two 
to  three  months.  The  males  live  on  the 
surface  near  the  burrows.  The  disease  is 
very  contagious,  through  contact  with  af- 
fected individuals  and  any  wearing  apparel 
or  bedclothing  that  they  may  have  used. 

TREATMENT.— Scabies  may  be  rap- 
idly cured  by  adopting  Hardy's  method; 
scrubbing  with  soap  and  water,  using  a 
brush  twenty  minutes;  the  same  pro- 
cedure thirty  minutes,  but  with  the  part 
immersed  in  the  soap-water;  rubbing  of 
the  part  with  the  Helmerich-Hardy  oint- 
ment: Carbonate  of  potash,  25  grains 
(1.62  Gm.);  sulphur,  50  grains  (3.25  Gm.); 
lard,  5  drams  (20  Gm.). — M.  This  is 
left  on  two  hours  and  the  parts  are  bathed 
as  before,  but  not  brushed.  Pruritus 
may  usually  be  relieved  by  means  of  a 
2  per  cent,  menthol  ointment.  Petrolatum 
is    sometimes    sufficient. 

The  simple  sulphur  ointment  thor- 
oughly, though  gently,  rubbed  in  at  night 
before  retiring,  followed  the  next  morn- 
ing by  a  warm  bath,  is  often  sufficient 
to  cure  scabies  when  persisted  in  for  two 
or  three  weeks,  but  the  underwear  should 
be  very  frequently  changed  and  boiled  for 
half  an  hour  or  baked  in  an  oven  at 
120°  C.  In  many  cases  the  ordinary  sul- 
phur ointment  is  too  strong;  it  is  always 
best  to  reduce  its  strength  by  mixing 
it  with  an  equal  quantity  of  benzoated 
lard.  Sulphur  baths  are  also  valuable, 
but     ointments     can    be    kept    in     contact 



longer  with  diseased  parts,  and  are  there- 
fore more  destructive  to  the  parasite. 

Julien  recommends  painting  the  entire 
body  with  balsam  of  Peru,  3  parts,  and 
glycerin,  1  part,  which  exercises  a  toxic 
action  on  the  Acarus.  No  soap  and  water 
should  be  used  before  its  application. 
With  a  l)rush  a  thin  layer  of  the  balsam 
is  laid  on  at  night,  followed  by  gentle 
rubbing.  A  bath  is  taken  on  the  fol- 
lowing morning.  The  remedy  causes  no 
irritation,  as  a  rule. 

For  scabies  in  infants  and  young  chil- 
dren, Hartzcll  recommends  equal  parts  of 
styrax  and  olive  oil,  or  1  or  2  drams  (4  to 
8  Gm.)  of  balsam  of  Peru  to  1  ounce  (30 
Gm.)  of  vaseline. 

Betanaphthol  (20  per  cent,  ointment), 
styrax,  creolin  (10  per  cent,  ointment), 
petroleum,  and  Hebra's  modification  of 
Wilkinson's  ointment  (unguentum  sul- 
phuris  comp.,  N.  F.,  which  contains  pre- 
cipitated chalk,  10;  sublimed  sulphur,  15; 
oil  of  cade,  15;  soft  soap,  30;  lard,  30 
parts)    have  been  used  with   success. 

Scabies  has  been  successfully  treated 
with  nicotine  soap.  It  is  of  a  dark-brown 
color,  and  may  be  scented  with  oil  of 
bergamot.  It  consists  of  tobacco  extract, 
5  per  cent.;  precipitated  sulphur,  5  per 
cent.;    and    ovei-fatty    soap,    90    per    cent. 

After  thorough  bathing  the  body  and 
limbs  may  be  rubbed  lightly  with  washed! 
sulphur,  less  than  ^  teaspoonful  for  each 
person;  this  to  be  followed  by  clean 
underclothes  and  clean  sheets  with  yi 
dram  (2  Gm.)  of  sulphur  dusted  between 
them.  If  this  is  repeated  every  second  or 
third  day  the  cure,  in  ordinary  cases,  is 
complete  in  a  week. 

For  the  treatment  of  secondary  pustular 
complications  Knowles,  1918,  recommends 
ammoniated  mercury  ointment,  20  to  40 
grains  (1.3  to  2.6  Gm.)  to  the  ounce  (30 
Gm.).  Incipient  boils  can  be  cured  by 
daily  rubbing  for  ten  minutes  with  25  per 
cent,  ichthyol  ointment.  If  they  are  re- 
current, an  autogenous  vaccine  should  be 
used.  Septic  ulceration  or  cellulitis  may 
require  rest  in  bed,  and  should  be  treated 
by  the  local  application  of  ammoniated! 
mercury  in  zinc  oxide  ointment. 

Another  plan  is  to  change  the  parasiti- 
cide during  the  treatment  (Montgomery). 
Use  a   sulphur-balsam    Peru  ointment   for 

three  days,  a  betanaphthol  ointment  for 
three  days,  and  a  creolin  ointment  for 
the  remaining  time. 

SCALP.  See  Head  and  Brain, 
Diseases  and  Injuries  of. 

SCAMMONY.— Scammony  is  the 
gum  resin  from  Convolvulus  scamnionia 
(fam.,  Convolvulaceae),  derived  from  the 
living  roots  of  the  plant.  Its  chief  con- 
stituent (80  to  95  per  cent.)  is  a  gluco- 
sidal  resin   called   scammonium. 

Scammonke  radix,  U.  S.  P.  (scammony). 
Dose,  4  to  8  grains  (0.25  to  0.5  Gm.). 

Rcshia  scammonke,  U.  S.  P.  (resin  of 
scammony).  Dose,  3  to  5  grains  (0.2 
to  0.3  Gm.). 

Extractum  colocynthidis  compositiim,  U.  S. 
P.  (compound  extract  of  colocynth,  con- 
taining 14  per  cent,  of  resin  of  scam- 
mony). Dose,  5  to  10  grains  (0.30  to 
0.60  Gm.). 

Pilida  catharticce  compositcc,  U.  S.  P.  (com- 
pound cathartic  pills  containing  1%  grains 
(0.08  Gm.)  of  compound  extract  of  colo- 
cynth in  each  pill).     Dose  2  pills. 

Pilulce  catliarticie  vegetahiles,  N.  F.  (vege- 
table cathartic  pills  containing  1  grain — 
0.06  Gm. — of  compound  extract  of  colo- 
cynth in  each  pill).     Dose  2  pills. 

It  is  also  an  ingredient  of  pilula  colo- 
cynthidis comp.  (pil.  cocciae),  N.  F.,  of 
pilul^e  colocynthidis  et  hyoscyami,  N.  F., 
and  of  pilula  colocynthidis  et  podophylli, 
N.  F. 

mony is  a  drastic  hydragogue  and  feebly 
cholagogue  purgative.  When  given  alone 
it  causes  considerable  griping.  It  is  un- 
certain in  action  by  reason  of  its  frequent 
adulteration  and  its  insolubility  in  the 
gastrointestinal  juices  if  they  are  acid. 
Gastritis  and  enteritis,  if  present,  contra- 
indicate  its  use.  Given  in  large  doses  it 
may  cause  severe  gastroenteritis  and 
fatal  purgation.  It  should  not  be  given 
alone,  but  combined  with  other  cathartics 
and  aromatics,  to  modify  its  harsh  action. 
Its  effects  are  usually  manifested  within 
four  hours. 

THERAPEUTIC  USES.— On  account 
of  its  tastelessness  it  is  a  favorite  pur- 
gative in  children,  combined  with  calomel 



and  triturated  with  sugar  of  milk.  It  is 
useful  in  cerebral  affections  and  dropsies, 
in  the  form  of  compound  extract  of 
colocynth.  It  is  useful  to  clear  the 
intestines  of  mucus  and  as  an  anthel- 
mintic against  both  roundworms  and 
tapeworms.  It  is  a  purgative  well  adapted 
to  cases  of  obstinate  constipation  and 
impaction  of  feces  and  in  cases  of  mania 
and   hypochondriasis.  W. 

SCARLET  FEVER.  —Scarlatina. 

DEFINITION.— Scarlet  fever  is 
an  acute,  infectious,  contagious,  erup- 
tive, disease  presenting-,  in  typical 
cases,  the  following  features :  After 
a  period  of  incubation  of  from  two  to 
four  days  there  is  a  sudden  onset  of 
sore  throat,  vomiting,  and  fever; 
within  twenty-four  hours  a  character- 
istic eruption  appears  and  continues 
for  about  six  days,  when  it  terminates 
in  desquamation. 

While  the  average  period  of  incu- 
bation of  scarlet  fever  (i.e.,  the  period 
between  exposure  and  the  appearance 
of  symptoms)  has  been  stated  to  be 
from  two  to  four  days,  with  a  maxi- 
mum of  seven,  the  latest  observations 
show  that  this  period  is  very  vari- 
able. The  limits  of  the  period  of 
incubation  are  practically  from  four 
to  twenty  days,  with  an  average  of 
ten  to  fourteen  days.  J.  W.  Scheres- 
chewsky  (Public  Health  Reports, 
Nov.  27,  1914). 

SYMPTOMS.— From  the  attack  so 
mild  that  diagnosis  is  difficult  to  the 
fiercely  malignant  form  we  see  every 
possible  degree  of  severity.  Notwith- 
standing this  variability  of  type,  the 
majority  of  cases  pursue  a  fairly 
uniform  course,  and  may,  with  pro- 
priety, be  called  ordinary  cases. 
Other  types  may  be  described  as  mild, 
severe,  and  malignant. 

Ordinary  Type. — The  invasion  is 
usually  sudden,  and  is  marked  by 
vomiting,  fever   sore  throat,  and  rapid 

pulse.  Occasionally  a  short  period  of 
malaise  precedes  the  onset  of  definite 
symptoms.  In  older  children  a  chill 
is  sometimes  the  first  symptom;  in 
younger  children  a  convulsion.  The 
vomiting  is  usually  repeated  several 
times,  and  is  not  accompanied  by 
nausea.  When  it  occurs  late  in  the 
disease  it  is  a  far  more  unfavorable 
symptom  than  at  the  outset.  The 
intensity  of  the  period  of  invasion  is 
usually  indicative  of  the  severity  of 
the  attack,  though  this  is  a  rule  sub- 
ject to  many  exceptions. 

The  temperature  is  frequently 
found  to  be  103°  F.  (39.4°  C.)  at  the 
first  visit  and  may  reach  104°  or  105° 
F.  (40°  or  40.5°  C.)  on  the  first  day. 
A  temperature  on  the  first  day  above 
104>^°  F.  (40.2°  C.)  indicates  a  severe 
attack;  below  102°  F.  (38.9°  C.)  a 
mild  attack.  The  highest  point  is 
commonly  reached  at  the  height  of 
the  eruption.  It  then  begins  to  sub- 
side and  becomes  normal  at  a  varying 
period,  ranging  from  the  ninth  to  the 
fifteenth  day.  The  fever  is  frequently 
remittent  and  in  mild  cases  almost 
intermittent  in  character.  There  is 
no  typical  temperature  range.  The 
febrile  stage,  even  in  quite  severe 
cases,  may  be  limited  to  six  or  seven 
days,  or  it  may  be  prolonged  to  four- 
teen or  fifteen  days  without  obvious 

Any  extensive  rise  or  fall  from  the 
level  maintained  during  the  fastigium, 
or  a  rise  interrupting  the  progressive 
lytical  resolution  indicates  an  inter- 
current or  complicating  condition 
and  not  an  essential  part  of  the  scar- 
latina pyrexia.  Lysis  in  scarlatina 
begins  on  the  fifth  or  sixth  day,  so 
that  if  a  febrile  case  shows  the  be- 
ginning of  lysis  on  the  second  day 
thereafter,  we  know  that  the  case  was 
four  days  old  on  admission.  The 
existence    of    a    complication    is    re- 



vealcd  by  a  sudden  rise  during  the 
lytical  stage,  the  character  of  the 
complication  being  often  shown  by 
the  temperature  curve,  and  the 
changes  in  the  pulse  and  respiration 
rate.  A  somewhat  septic  curve  with 
increase  in  pulse  and  respiration  sug- 
gests bronchopneumonia;  a  cardiac 
complication  may  be  suspected  from 
a  suspension  of  the  lytical  tempera- 
ture curve  with  greatly  increased 
pulse  rate  and  a  moderate  increase  in 
respiration;  a  meningitis  or  menin- 
gismus  attending  an  otitis  media  or 
mastoiditis  is  frequently  indicated 
through  an  interruption  of  the  stage 
of  lysis  by  an  increase  of  fever  of 
septic  character  coupled  with  a  lower 
pulse  rate  than  is  usual  at  the  height 
of  the  fever,  although  it  might  also 
indicate  the  presence  of  an  acute  glo- 
merular nephritis.  Nephritis  is  not 
as  frequent  in  hospital  cases  as  in 
private  practice  for  two  reasons:  The 
patient  is  kept  strictly  in  bed  until 
desquamation  is  almost  complete  and 
is  kept  on  a  fluid  diet  until  he  has 
well  passed  the  stage  of  acute  symp- 
toms. H.  W.  Berg  (Med.  Record, 
May  11,   1912). 

In  a  study  of  17  cases  of  uncom- 
plicated scarlet  fever  and  of  2  cases 
of  scarlet  fever  with  nephritis,  the 
writers  found  that  examination  of  the 
urine  for  albumin  is  of  more  value 
than  the  functional  tests  for  the  de- 
tection of  the  onset  of  kidney  com- 
plication. Veeder  and  Johnston 
(Amer.  Jour,  of  Dis.  of  Children, 
Mar.,   1920). 

A  pulse  abnormally  rapid  as  com- 
pared with  the  height  of  the  tempera- 
ture is  quite  characteristic  of  scarlet 
fever.  It  is  often  150  on  the  first  day, 
and  continues  rapid  throughout  the 

One  of  the  earliest  symptoms  is 
sore  throat.  The  fauces,  tonsils,  and 
pharynx  are  of  a  imiform  bright-red 
color,  and  on  the  hard  palate  numer- 
ous dark-red  macules  may  be  seen. 
In   mild   cases   the   throat   symptoms 

may  be  very  slight;  in  more  severe 
cases  the  tonsils  may  be  studded  with 
follicular  spots,  or  smeared  over  with 
a  tenacious  exudate  closely  resem- 
bling a  pseudomembrane.  There  is 
frequently  a  discharge  from  the  nose, 
which  may  consist  of  clear,  tenacious 
mucus  or  mucopus.  The  glands  at 
the  angle  of  the  jaw  frequently  be- 
come enlarged.  Gregor  of  Petrograd 
has  recently  reported  observations 
upon  the  thyroid  and  believes  that 
there  is  a  special  form  of  scarlatinal 
thyroiditis.  It  is  possible  that  these 
changes  may  have  some  bearing  upon 
the  occurrence  of  thyroid  disease  in 
later  life.  The  spleen  is  not  usually 

Not  one  of  the  individual  symp- ' 
toms  can  be  depended  upon  to  estab- 
lish the  diagnosis.  Next  to  the 
throat,  the  condition  of  the  tongue 
is  the  most  reliable  symptom,  some 
enlargement  of  the  papillae  of  the  tip 
and  border  being  usually  observable, 
although  this  symptom  is  much  more 
frequently  missing  than  is  the  angina 
and  may  occur  in  other  conditions. 
Miller  (Arch,  of  Pediatrics,  Apr., 

As  the  disease  progresses,  the 
tongue,  which  is  at  first  coated,  often 
assumes  the  so-called  strawberry  ap- 

Considerable  confusion  exists  as 
to  what  the  strawberry  tongue  really 
is.  It  is  not  a  white  tongue  with  red 
papilL-e ;  such  a  tongue  is  seen  in  vari- 
ous conditions.  The  true  strawberry 
tongue  was  originally  described  by 
Flint  as  follows :  "The  tongue  in  the 
first  days  is  usually  coated.  In  the 
progress  of  the  disease  the  tongue 
usually  exfoliates,  leaving  the  surface 
clean  and  reddened  and  the  papillae 
enlarged.  The  appearance  is  strik- 
ingly like  that  of  a  ripe  strawberry. 

Differential  Diagnosis  of  Eruptions  in  Children's  Diseases. 

1.  Scarlet  fever.  5.  Strawberry  tongue  of  scarlet  fever. 

2.  Scarlet  fever ;  desquamation.     6.  Variola. 

3.  Rubeola.  7.  Variola  ;  confluence. 

4.  Rubella.  8.  Varicella. 

9.  Variola-like  varicella. 



The  strawberry-like  tongue  is  a 
pathognomonic  symptom ;  it  is  pecul- 
iar to  this  disease.  It  is  often,  but 
not  uniformly,  present."  The  term 
should  be  applied  to  the  red,  clean 
tongue  with  prominent  papillae  which 
follows  a  coated  tongue. 

The  eruption  usually  appears  with- 
in twenty-four  hours  after  the  initial 
vomiting.  It  is  not  infrequently  seen 
after  twelve  hours,  and  is  sometimes 
delayed  for  thirty-six  hours  and  in 
rare  cases  to  the  fourth  or  fifth  day. 
There  is  frequently  intense  itching 
or  burning  of  the  skin.  The  rash  is 
usually  well  developed  during  the 
second  day  of  its  appearance.  It 
then  continues  from  four  to  six  days, 
when  it  gradually  subsides.  It  usu- 
ally appears  first  over  the  front  of  the 
neck  and  upper  part  of  the  chest.  It 
consists  of  minute  points  of  bright- 
scarlet  color  closely  grouped  together 
on  a  slightly  reddened  skin.  They 
become  confluent  in  places,  forming 
bright-scarlet  patches,  but  over  the 
most  of  the  surface  they  remain  dis- 
crete throughout.  Being  hyperemic 
in  nature,  the  rash  disappears  on 
pressure,  leaving,  for  a  perceptible 
time,  a  white  spot.  An  eruption  of 
very  fine  vesicles  is  seen  in  rare  in- 
stances, and  occasionally  a  blotchy 
eruption  appears  early  on  the  face,  but 
subsides  as  the  typical  rash  develops. 

One  of  the  most  characteristic 
symptoms  of  scarlet  fever  is  the  des- 
quamation. It  rarely  begins  before 
the  sixth  day,  and  is  frequently  de- 
layed until  the  second  week.  It  ap- 
pears first  on  the  neck  and  between 
the  fingers.  It  begins  as  fine,  branny 
scales,  but  soon  changes  to  large 
lamellar  scales.  Sometimes  the  skin 
can  be  peeled  oflf  in  strips.  It  con- 
tinues from  ten  to  thirty  days,  and  is 

most  persistent  where  the  skin  is 
thickest.  It  frequently  continues 
about  the  fingers  and  nails  after  other 
portions  of  the  body  are  clear,  which 
explains  the  readiness  with  which  the 
disease  is  conveyed  by  letters.  When 
the  skin  has  received  careful  atten- 
tion, the  desquamation  is  sometimes 
almost  imperceptible.  In  rare  in- 
stances a  second  desquamation  occurs. 

The  urine  becomes  scanty  and 
high  colored  during  the  febrile  stage, 
and  frequently  contains  a  slight 
amount  of  albumin  and  sometimes 
blood  and  hyaline  casts.  Except  in 
the  more  severe  forms,  suppression  is 
rare  and  dropsy  still  rnore  so.  These 
symptoms  usually  subside  as  the  fever 
falls.  The  kidney  symptoms  at  this 
stage  rarely  prove  serious.  They 
may,  however,  do  so,  and  always  de- 
mand attention.  The  more  serious 
kidney  symptoms  occur  later  and  will 
be  considered  as  a  complication. 

Mild  Type. — Scarlet  fever  is  some- 
times so  mild  as  to  render  diagnosis 
very  difficult.  The  symptoms  may  be 
so  slight  that  medical  aid  is  not 
sought.  As  a  rule,  however,  there  is 
an  onset  of  vomiting,  fever,  and  sore 
throat,  as  in  the  ordinary  type,  but 
none  of  the  symptoms  are  urgent. 
The  vomiting  is  not  persistent,  the 
temperature  does  not  rise  above  102"" 
or  103°  F.  (38.9°  or  39.4°  C),  and  the 
throat  presents  only  the  symptoms  of 
mild  pharyngitis.  I  have  seen  an  un- 
doubted case  in  which  the  tempera- 
ture never  rose  to  101°  F.  (38.4°  C). 
It  may  become  normal  on  the  fourth 
or  sixth  day.  The  eruption  is  often 
very  faint,  and  may  not  appear  on  the 
face.  It  may,  however,  be  bright  and 
distinctive  for  twenty-four  hours  and 
then  fade  away  so  rapidly  as  to  have 
disappeared  by  the  fifth  day.     In  rare 



instances  it  is  an  evanescent  rash 
which  disappears  entirely  within 
twenty-four  hours.  Nephritis  may  be 
a  sequel,  due  in  many  cases  to  ex- 
posure and  lack  of  care :  the  natural 
results  of  so  mild  an  illness.  Owing 
to  this  lack  of  care  and  isolation,  the 
patient  may  become  very  dangerous 
to  others.  It  is  by  these  mild  cases 
that  the  disease  is  sometimes  sown 
broadcast.  A  mild  attack  in  one  child 
may  produce  a  malignant  one  in  an- 

Severe  Type. — Not  only  are  the 
symptoms  of  this  type  severe,  but  the 
various  stages  are  prolonged.  The 
fever  may  continue  for  three  weeks  or 
more,  and  the  stage  of  desquamation 
for  even  a  longer  time.  A  fatal  ter- 
mination is  common,  death  occurring 
usually  during  the  second  week.  The 
chief  peculiarity  which  distinguishes 
this  from  the  ordinary  type  is  the 
presence  of  septic  symptoms  due  to 
streptococcic  infection.  The  type 
might,  therefore,  with  propriety  be 
called  complicated  type.  The  throat 
is  usually  the  first  to  show  the  evi- 
dence of  streptococcic  invasion.  On 
the  third  day,  and  in  some  cases  on 
the  first  or  second  day,  a  membranous 
exudate  appears  on  the  tonsils  and 
soon  invades  the  pharynx  and  naso- 
pharynx. A  purulent  nasal  discharge 
appears,  and  the  lymphatic  glands  at 
the  angle  of  the  jaw  begin  to  swell, 
the  cellular  tissues  being  so  involved 
as  to  often  cause  immense  enlarge- 
ment. The  Eustachian  tubes  are  in- 
volved, and  purulent  otitis  media  fol- 
lows ;  but  the  lar3aix  commonly 

In  10,000  cases  recorded  in  ten 
years,  2L06  per  cent,  had  ear  disease. 
There  are  two  forms  of  scarlatinal 
otitis.  The  first  is  a  comparatively 
mild  ordinary  inflammation,   and  has 

no  rchuion  to  the  scarlet  fever  except 
that  it  occurs  at  the  same  time.  It 
is  most  frequent  in  cases  with  little 
or  no  throat  trouble.  The  second 
type  is  the  so-called  scarlatino-diph- 
theritic  or  necrotic  otitis,  and  is 
brought  about  by  the  same  specific 
cause  as  the  scarlet  fever  itself.  It 
differs  from  the  first  type  in  being 
very  much  more  severe  and  involv- 
ing extensive  necrosis  of  the  soft 
parts  and  bones.  P.  Manasse 
(Monats.  f.   Kinderheilk.,  July,   1913). 

The  urine  contains  albumin  and 
perhaps  blood-cells  and  hyaline  and 
epithelial  casts.  Symptoms  of  gen- 
eral septic  infection  rapidly  super- 
vene. There  is  low  delirium  or 
stupor;  the  child  refuses  nourishment 
and  may  die  from  exhaustion ;  but 
sudden  death  is  not  uncommon. 
Others,  after  overcoming  one  com- 
plication after  another,  slowly  recover 
after  a  tedious  convalescence. 

Malignant  Type. — Though  very 
rare,  malignant  scarlet  fever  does 
sometimes  occur.  It  begins  with 
convulsions  and  hyperpyrexia.  The 
scarlatinal  poisoning  may  be  so  in- 
tense as  to  cause  death  within  twenty- 
four  hours.  More  commonly,  death 
does  not  occur  before  the  third  or 
fourth  day,  the  patient  being  coma- 
tose or  delirious.  The  nervous  symp- 
toms are  so  marked  that  some 
waiters  have  given  to  this  type  the 
name  of  cerebral  scarlet  fever.  In  a 
case  of  my  owii  the  initial  symptoms 
were  convulsions,  hyperpyrexia,  and 

The  writer  encountered  16  cases  of 
scarlet  fever  with  the  clinical  mani- 
festations of  meningitis  among  400 
scarlet-fever  patients  in  the  course  of 
nine  months.  When  the  fluid  escaped 
under  high  pressure  on  luml)ar  punc- 
ture, great  relief  followed,  but  when 
the  pressure  was  not  high,  the  lum- 
bar puncture  did  not  seem  to  benefit, 



but  it  proved  very  instructive  by  per- 
mitting the  exclusion  of  a  suppura- 
tive or  serous  meningitis.  The  prog- 
nosis did  not  seem  to  be  affected  by 
the  pseudomeningitis,  as  the  severity 
of  the  scarlet  fever  was  what  deter- 
mined the  outcome.  Sachs  (Jahrb.  f. 
Kinderheilk.,  Bd.  Ixxxiii,  Suppl, 

Surgical  Scarlet  Fever. — Patients 
who  have  undergone  surgical  opera- 
tions are  unquestionably  very  sus- 
ceptible to  scarlet  fever.  Such  scarlet 
fever,  however,  is  not  essentially  dif- 
ferent from  the  usual  disease.  It  is 
simply  scarlet  fever  in  a  surgical  case. 
It  is,  no  doubt,  true,  as  Osier  has 
shown,  that  the  eruption  which  has 
frequently  led  to  a  diagnosis  of  scar- 
let fever  is  nothing  more  than  the  red 
rash  of  septicemia.  It  is  a  fact  that 
surgical  scarlet  fever  is  much  less 
common  since  surgical  septicemia  has 
become  less  frequent. 

In  12  out  of  28  cases  of  scarlet 
fever  developed  among  hospital  pa- 
tients, the  infection  followed  an  ex- 
tensive operation  and  in  1  a  severe 
burn.  The  incubation  was  only  three 
days  in  10  and  from  five  to  eight  days 
in  the  others.  The  infection  doubt- 
less occurred  in  the  operating  room. 
Kredel  (Arch.  f.  klin.  Chir.,  Bd. 
Ixxxvii,  nu.  4,  1908). 


— Age  is  first  among  the  predisposing 
causes.  The  disease  is  rare  under  one 
year,  l)ut  I  have  seen  an  undoubted 
attack  of  scarlet  fever  in  an  infant  of 
one  week.  Up  to  5  years  the  suscep- 
tibility steadily  increases  and  reaches 
its  maximum;  after  8  years  it  rapidly 
decreases,  and  is  slight  during  adult 
life.  Sex  does  not  influence  its 

A  patient  of  the  writer  developed 
typical  scarlet  fever  while  nursing 
her  month-old  babe.  The  disease  ran 
the    usual    course    without    complica- 

tions and  the  infant  continued  to 
nurse  and  thrive  without  contracting 
the  disease.  Scarlet  fever  is  rare  in 
infants  less  than  a  year  old,  and  it  is 
possible,  he  thinks,  that  the  mother's 
milk  confers  a  passive  immunity  on 
the  child.  Delmas  (Arch,  des  med. 
des  enfants,  Feb.,  1911). 

Scarlet  fever  is  rare  in  breast 
babies,  particularly  during  the  first 
six  months.  It  is  more  common  in 
boys.  The  complications  during  the 
first  half-year  are  more  frequent  and 
more  severe,  the  most  serious  being 
gangrenous  sore  throat,  and  the  most 
frequent  lymphadenitis.  L.  V.  Ak- 
senoff  (Roussky  Vratch,  Sept.  29, 

Of  3603  cases  of  scarlet  fever  an- 
alyzed by  Pospischill  and  Weiss 
there  were  only  28  cases  during  the 
first  year,  and  these  had  their  in- 
cidence during  the  later  months  of 
the  year.  The  author  had  the  oppor- 
tunity of  observing  9  cases  of  scar- 
let fever  in  infants  less  than  3 
months  of  age  and  1  case  in  an  in- 
fant 9  months  old.  With  the  excep- 
tion of  the  last,  all  were  the  infants 
of  mothers  suffering  from  scarlet 

The  clinical  phenomena  in  all  of 
these  cases  were  somewhat  as  fol- 
lows: From  three  to  seven  days  fol- 
lowing the  onset  of  the  disease  in 
the  mother  the  infant  took  sick  with 
a  moderate  fever  lasting  from  two  to 
four  days.  There  was  the  character- 
istic tongue  with  the  reddening  of 
the  tonsils  and  of  the  soft  palate.  In 
no  instance  was  there  any  membrane 
on  or  necrosis  of  the  tonsils.  There 
was  at  first  some  difficulty  in  nurs- 
ing and  a  disinclination  to  take  the 
breast.  Carl  Levi  (Beitrage  z.  Klinik 
d.  Infektionsk.  u.  z.  Immunit.,  Bd.  ii, 
nu.  2,   1914). 

That  scarlet  fever  is  an  infectious 
disease  does  not  admit  of  doubt,  but 
the  specific  germ  has  not  yet  been 
discovered.  Three  theories  have  been 
advanced  as  to  its  etiology,  namely, 
that  it  is  due  to  (1)  streptococci;  (2) 



protozoa;  (3)  a  filterable  or  ultra- 
microscopic  virus.  That  it  is  caused 
by  a  protozoon  is  possible,  but  the 
theory  has  by  no  means  l)een  con- 
firmed. The  filterable  theory  cannot 
be  excluded,  but  is  largely  theoretical. 

The  scrum  of  scarlet-fever  patients 
contains  specific  antibodies  for  an 
unknown  virus.  This  unknown  virus 
seems  to  be  present  especially  in  the 
cervical  lymph-nodes.  K.  K.  Koess- 
ler  and  J.  M.  Koessler  (Jour,  of  In- 
fectious  Dis.,   Nov.,   1911). 

It  has  been  fully  demonstrated  that 
streptococci  play  an  important  role 
in  the  causation  of  many  of  the  symp- 
toms. It  has  been  urged  by  some  that 
streptococci  are  the  cause  of  the  dis- 
ease itself,  but  this  ground  is  unten- 
able. They  are,  however,  the  cause 
of  the  pseudomembranous  exudations 
of  the  throat,  and  undoubtedly  cause 
the  otitis  and  adenitis,  and  probably 
the  nephritis,  pneumonia,  and  joint 
lesions.  The  streptococci  thus  far 
found  cannot  be  differentiated  from 
other  streptococci.  The  evidence 
fails  to  support  the  belief  that  the 
streptococcus  of  scarlet  fever  dififers 
from  that  of  other  infectious  processes. 

The  writer  examined  the  blood  of 
523  children  suffering  from  scarlatina 
for  streptococci,  and  concludes  that 
the  organism  is  found  only  in  2.1  per 
cent,  of  all  cases.  V.  N.  Klimenko 
(Arch,  des  Sci.  Biol.,  St.  Petersburg, 
No.  3,  1912). 

The  cause  of  scarlet  fever  has 
never  been  definitely  determined  and 
the  attempts  to  transmit  it  to  mon- 
keys have  met  with  only  very  limited 
success.  The  writer  believes  that  it 
is  a  streptococcic  infection,  though 
this  assumption  has  not  been  proved 
or  disproved  with  certainty.  Many 
clinical  facts  seem  to  prove  that  a 
special  susceptibility  on  the  part  of 
the  patient  is  an  important  factor  in 
the  development  of  scarlet  fever,  and 
that  it  may  be  regarded  as  an  anaphy- 

la':tic  reaction  to  a  streptococcic  in- 
fection. Kretschmer  (Jahrb.  f.  Kin- 
derhcilk.,  Sept.,  1913). 

Whatever  the  cause  of  the  primary 
disease  may  be  proved  to  be,  it  is 
certain  that  streptococci  are  the  di- 
rect cause  of  the  secondary  symptoms. 
They  are  so  constant  in  their  pres- 
ence, and  so  active  in  the  production 
of  the  more  serious  symptoms  and 
complications,  that  they  must  be  re- 
garded as  important  factors  in  the 
production  of  the  clinical  picture 
which  we  know  as  scarlet  fever.  The 
disease  as  it  commonly  appears  is  a 
mixed  infection,  the  more  malignant 
and  fatal  symptoms  being  due  not  so 
much  to  the  primary  as  the  secondary 

Staphylococci  and  diphtheria  bacilli 
are  sometimes  found  in  conjunction 
with  streptococci. 

The  inclusion  bodies  studied  by 
Dohle,  of  Kiel,  have  been  farther 
studied  by  Nicoll  and  Williams,  of 
New  York.  These  are  small  bodies 
found  in  the  protoplasm  of  the  poly- 
morphonuclear leucocytes.  While 
some  observers  regard  them  of  im- 
portance in  the  diagnosis  of  scarlet 
fever,  it  cannot  be  said  that  their  true 
significance  has  as  yet  been  deter- 
mined. Thev  are  rarely  found  after 
the  sixth  day  of  the  disease. 

Other  diagnostic  signs  have  in  recent 
years  been  proposed,  the  value  of  which, 
as  is  the  case  with  Dohle's  sign  described 
above,  has  not  as  yet  been  determined. 

Dohle's  leucocytic  inclosures  are 
found  in  many  other  conditions. 
Their  absence,  however,  is  of  diag- 
nostic significance,  because  they  are 
found  in  the  early  stages  of  all  scar- 
let fevers;  a  negative  result  therefore 
excludes  scarlet  fever,  and  the  early 
diagnosis  of  the  disease  may  be  made 
by  their  presence.  A.  Belak  (Deut. 
med.  Woch.,  Dec.  26,  1912). 



The  writer  has  examined  a  number 
of  scarlet-fever  patients  for  the  cell 
inclusions,  14  with  pneumonia  and  a 
number  of  patients  with  other  affec- 
tions, including  11  with  anemia  and 
5  with  measles.  The  inclusions  were 
found  constantly  in  every  case  of  re- 
cent febrile  scarlet  fever,  less  numer- 
ous in  the  milder  cases  and  declining 
as  the  disease  progressed.  After  the 
seventh  day  scarcely  any  were  to  be 
found.  They  are  no  aid  in  diagnosis, 
therefore,  after  the  first  few  days, 
and  they  are  not  pathognomonic  for 
scarlet  fever,  as  they  occur  with  the 
same  constancy  and  as  abundantly 
in  croupous  pneumonia  in  children. 
Schwenke  (Miiiich.  med.  Woch.,  Apr. 
8,  1913). 

Leede's  sign  (Miinch,  med.  Woch..  Feb. 
7,  1911)  is  obtained  in  the  following  way: 
Apply  a  rubber  band  to  the  arm  suffi- 
ciently tight  to  render  the  veins  very  con- 
spicuous and  the  forearms  and  hands 
cyanotic,  without  obliterating  pulse.  After 
ten  or  fifteen  minutes  remove  the  band. 
Put  the  skin  of  tlexor  surface  of  elbow  on 
stretch,  to  render  it  anemic.  Hemorrhagic 
extravasations  on  this  surface,  appearing 
as  very  fine,  dark  points,  favor  a  diagnosis 
of  scarlatina,  while  their  absence  speaks 
strongly  against  the  presence  of  this 

The  writer  confirms  the  findings  of 
Rumpel  and  Leede  in  regard  to 
petechial  hemorrhages  from  artificial 
stasis  in  scarlet  fever.  He  has  no- 
ticed this  phenomenon  frequently  in 
making  blood  examinations  in  scar- 
let fever,  and  found  it  positive  in  26 
out  of  a  series  of  32  cases.  In  doubt- 
ful cases  in  children,  where  the 
throat  signs  were  suspicious,  a  posi- 
tive result  was  always  confirmed  by 
the  development  of  typical  scarlet 
fever.  Bennecke  (Miinch.  med. 
Woch.,  Bd.  Iviii,  S.  740,   1911). 

Study  of  100  patients  with  various 
affections  to  determine  the  diagnostic 
value  of  the  Leede  sign.  It  was  not 
positive  in  healthy  controls,  but  was 
found  positive  in  heart  disease,  bron- 
chitis, pneumonia,  acute  hepatitis  and 
nephritis,    cerebral    hemorrhage,    ty- 

phoid and  puerperal  fevers,  and  tabes. 
These  findings  deprive  the  sign  of 
any  specific  diagnostic  value.  It 
seems  to  be  a  manifestation  of  dimin- 
ished resistance  in  the  walls  of  the 
smaller  blood-vessels.  U.  Morandi 
(Gazz.  degli  Ospedali,  Apr.  2,  1912). 
The  tourniquet  or  Rumpel-Leede 
sign  occurs  regularly  in  scarlet  fever, 
but  is  found  also  in  measles,  and  in 
some  cases  of  diphtheria,  syphilis 
and  tonsillitis.  It  permitted  an  early 
diagnosis  of  scarlet  fever  in  a  num- 
ber of  the  writer's  cases,  before  the 
eruption  developed.  Meyer  (Deut. 
med.  Woch.,  Oct.  24,  1912). 

Pastia's  sign  (La  Tribune  medicale.  No. 
46,  p.  726,  1910)  consists  in  a  deep-rose- 
colored,  linear  exanthem  in  the  skin-folds 
of  the  anterior  aspect  of  the  elbow.  The 
lines  are  usually  two  to  four  in  number. 
They  can  be  caused  to  stand  out  in  con- 
trast by  exerting  gentle  pressure  on  skin, 
then  quickly  removing  it.  It  was  uni- 
formly present  in  12)  cases,  appearing  with 
the  rash  and  usually  lasting  two  or  three 
weeks  longer  than  the  rash.  It  occurs  in 
other  diseases,  but  only  in  such  as  can 
easily  be  differentiated  from  scarlatina. 

The  Wassermann  reaction,  according  to 
Rubens  (Berl.  klin.  Woch.,  Oct.  19,  1908), 
will,  under  certain  conditions  that  have 
remained  undetermined,  prove  positive  in 
Sicarlet  fever  as  it  does  in  syphilis. 

Case  of  scarlet  fever  in  a  girl,  16 
years  old,  in  which  Wassermann's 
test  for  syphilis  produced  a  posi- 
tive reaction.  Four  weeks  after  the 
commencement  of  the  illness  the 
test  became  negative,  and  remained 
so.  Holzmann  (Miinch.  med.  Woch., 
Apr.  6,  1909). 

The  writer  examined  55  scarlet- 
fever  patients  and  obtained  a  positive 
Wassermann  reaction  in  18.  This 
positive  reaction  occurs  after  the 
subsidence  of  the  acute  symptoms 
and  generally  only  in  the  severer 
cases.  It  usually  disappears  by  the 
end  of  the  period  of  desquamation 
and  has  no  effect  on  the  diagnostic 
importance  of  the  reaction  in  syphilis. 
Jakobovics  (Jahrb.  f.  Kinderheilk., 
Feb.,  1914). 




The  diazo-reaction  seems  to  afford  aid 
in  identifying  scarlet  fever  from  measles. 
The  diazo-reaction  was  found  pcjsi- 
tive  by  the  writers  in  17.3  per  cent, 
of  scarlet  fever,  but  also  12.9  per 
cent,  of  diphtheria  patients  during  the 
first  week  of  these  infections.  It  is 
during  this  week  that  scarlatiniform 
serum  rashes  are  so  apt  to  develop 
and  make  a  differential  diagnosis  from 
scarlet  fever  quite  difficult.  The  per- 
centage of  positive  reactions  in 
serum  sickness  was  much  lower.  The 
value  of  the  diazo-reaction  in  dif- 
ferential diagnosis  is  very  slight.  Yet 
the  reaction  being  positive  in  75  per 
cent,  of  cases  of  measles,  a  negative 
reaction  in  a  case  presenting  a  mor- 
billiform rash  is  of  value  in  the  dif- 
ferential diagnosis  from  measles. 
Woody  and  Kolmer  (Arch.  of 
Pediat.,  Jan.,  1912). 

Copper  sulphate  may  produce  a  fleet- 
ing exanthem  and  other  signs  suggesting 
scarlet   fever. 

Copper  sulphate  is  used  for  spray- 
ing grape-vines  in  France,  and  2 
children  who  had  been  eating  grapes 
thus  sprayed  developed  symptoms 
deceptively  simulating  scarlet  fever. 
The  diagnosis  of  scarlet  fever  was 
made  without  hesitation,  but  it  had 
to  be  revised,  as  the  children  were 
quite  normal  again  by  the  fifth  day. 
Vomiting,  sore  throat,  headache  and 
a  lively  rash  over  the  entire  body 
were  the  main  symptoms.  Lasalle 
(Arch,  de  med.  des  enfants,  Feb., 

Leucocytosis  is  found  in  virtually 
all  cases,  the  maximum  being  reached 
during-  the  first  week  in  uncom- 
plicated cases.  It  then  gradually 

Comparing  the  findings  in  10  cases 
of  scarlet  fever  with  those  in  7  of 
typhoid,  pneumonia,  gonorrhea  or 
gastroenteritis,  the  writer  concludes 
that  a  typical  polynucleosis  accom- 
panies the  onset  of  the  eruption  in 
scarlet  fever.  It  is  pronounced  and 
remains  high  during  the  first  two  or 
three   days   of   the   eruption,   even   in 

very  young  children.  The  number  of 
mononuclears  declines,  especially  the 
proportion  of  lymphocytes.  The 
eosinopliiles  fluctuate,  but  are  gener- 
ally increased,  especially  by  the  end 
of  a  few  days  of  the  disease.  Pater 
(Arcli.  de  med.  des  enfants,  Aug. 

Transmission. — Grave  doubts  have 
been  expressed  in  recent  years  re- 
garding the  ability  of  the  desquama- 
tion scales  to  transmit  the  disease. 
No  positive  statements  can  be  made 
until  the  actual  cause  of  the  disease 
has  been  demonstrated.  I  can  only 
express  the  personal  opinion  that  evi- 
dence against  the  belief  in  the  trans- 
mission of  the  disease  by  desquama- 
tion scales  and  clothing  has  not  been 
fully  established. 

Scarlet  fever  is  not  communicable 
in  the  early  stages,  but  is  transmitted 
mainly  by  the  secretions  from  the 
mouth,  nose  and  ears.  The  exfoliated 
epithelium,  after  the  fourth  or  fifth 
week,  does  not  seem  able  to  carry 
contagion.  Zangger  (Correspondenz- 
blat.  f.  Schweizer  Aerzte,  Mar.  1, 

Many  cases  of  scarlet  fever  are  so 
atypical  as  to  go  unrecognized  until 
a  sequela  makes  its  appearance.  It 
is  a  disease  of  direct  infection;  it  is 
rarely  carried  by  a  second  person  or 
object.  The  most  contagious  period 
is  early  in  the  disease  during  the 
period  of  angina,  rash  and  tempera- 
ture; therefore,  the  danger  of  trans- 
mitting the  disease  during  the  des- 
quamation period  is  much  exagger- 
ated. Kerley  (Amer.  Jour,  of  Dis. 
of  Children,  Jan.,  1911). 

So  long  as  nasal  and  aural  dis- 
charges exist,  just  so  long  will  cases 
of  scarlet  fever  be  infective.  Sexton 
(Arch,  of  Diag.,   May,   1915). 

Experiments  seem  to  show  that  the 
specific  germ  of  scarlet  fever  exists  in 
the  blood,  for  inoculation  with  the 
cerum  into  susceptible  animals  pro- 
duces a  typical  attack  of  the  disease. 



It  is  also  found  in  the  various  secre- 
tions, as  shown  by  their  power  to 
generate  the  disease. 

The  micro-organism,  while  more 
tenacious  of  life  than  is  that  of  most 
other  diseases,  either  lacks  the  power 
of  gaining  a  foothold,  when  implanted 
in  the  system,  or  is  less  readily  con- 
veyed through  the  air.  It  is  at  least 
a  fact  that  many  more  children  escape 
scarlet  fever  than  measles,  and  its 
spread  is  more  readily  controlled. 

The  chief  source  of  infection  is  the 
patient  himself,  but  the  area  of  con- 
taoion  is  limited  to  a  few  feet.  The 
desquamation  scales  have  long  been 
regarded  as  extremely  infectious. 
Their  retention  by  clothing,  bedding, 
and  the  walls  of  the  rooms  is  one  of 
the  most  common  causes  of  infection. 
The  purulent  secretions  from  the 
throat,  nose,  and  ear  are  also  very 
infectious,  and  are  probably  the  chief 
sources  of  infection. . 

Scarlet  fever  is  spread  by  indirect 
infection  more  frequently  than  any 
other  disease  except  diphtheria.  Its 
specific  micro-organism  is  more  tena- 
cious of  life  than  that  of  any  other 
disease,  except,  perhaps,  smallpox. 
Authentic  cases  have  been  reported  in 
which  it  maintained  its  vitality  for  a 
year  or  more.  It  may  be  conveyed 
from  one  child  to  another  in  the  fur 
of  cats  and  dogs,  and  it  is  probable 
that  these  animals  may  suffer  from 
the  disease.  The  contagion  clings  to 
rooms  with  great  tenacity,  being  usu- 
ally lodged  in  the  wall-paper  or  in 
cracks  of  the  walls,  ceilings,  and 
floors.  The  conveyance  of  scarlet 
fever  by  milk  and  other  articles  of 
food  is  undoubted. 

The  celebrated  epidemics  of  Hen- 
don  and  Wimbledon  were  believed  by 
Dr.  Klein  to  be  due  to  scarlet  fever 

in  the  cows,  but  this  belief  has  not 
been  substantiated.  It  is  probable 
that  the  disease  from  which  those 
cows  suffered  was  not  true  scarlet 

An  .epidemic  of  scarlet  fever  that 
occurred  in  the  city  of  Evanston,  near 
Chicago,  in  the  winter  of  1906-7 
showed  conclusively  a  connection  be- 
tween the  extension  of  the  disease 
and  the  use  of  milk  from  a  certain 
source  of  supply.  This  source  had 
been  under  suspicion  on  account  of 
a  number  of  cases  of  scarlatina  oc- 
curring during  the  previous  summer 
and  fall,  but  the  real  epidemic  began 
early  in  January,  1907,  and  was  at  its 
height  between  the  14th  and  19th  of 
the  month.  Whole  families  were  at- 
tacked in  a  day,  and  a  notable  pro- 
portion of  the  patients  were  adults. 
H.  B.  Hemenway  (Jour.  Amer.  Med. 
Assoc,  Apr.  4,  1908). 

The  disease  has  been  conveyed 
by  letters  written  by  hands  in  the 
stage  of  desquamation.  An  attendant 
upon  a  case  of  scarlet  fever  may  carry 
the  infection  to  other  children  by  the 
clothes,  hands,  or  beard. 

The  portal  of  entrance  in  most  cases 
is  undoul)tedly  the  nasopharynx.  It 
is  here  that  the  first  local  symptoms 
appear,  and  all  the  evidence  points  to 
the  fact  that  both  the  primary  and 
secondary  micro-organisms  commonly 
enter  the  system  at  this  point. 

In  cities  scarlet  fever  is  endemic,  a 
few  cases  appearing  in  the  health- 
reports  every  week,  but  at  intervals  it 
becomes  epidemic,  usually  during  the 
fall  and  winter.  Epidemics  of  scarlet 
fever  usually  spread  very  slowly  as 
compared  with  those  of  measles. 

Period  of  Incubation. — The  period 
of  incubation  is  shorter  than  that  of 
any  other  infectious  disease,  except, 
perhaps,  grippe  and  diphtheria.  Tlie 
extremes  range  from  a  few  hours  to 
fifteen  days.     In  87  per  cent,  of  cases 



Holt  found  the  period  to  be  less  than 
six  days  and  in  66  per  cent,  between 
1\vo  and  three  days. 

Period  of  Infection. — The  period  of 
infection  is  long.  The  disease  is  not 
infectious  during  the  period  of  incu- 
bation, but  it  may  be  so  from  the  first 
appearance  of  changes  in  the  throat. 
The  most  actively  contagious  period 
is  at  the  height  of  the  febrile  stage: 
on  the  third,  fourth,  and  fifth  days. 
The  infectious  power  then  diminishes, 
but  increases  again  during  the  stage 
of  desquamation.  The  period  of  con- 
tagion continues  until  the  last  evi- 
dences of  desquamation  have  disap- 
peared. The  purulent  discharges 
from  the  throat,  nose,  and  ears  are 
capable  of  infecting  others,  and  isola- 
tion should  not  be  relaxed  until  they 
have  disappeared.  The  conventional 
forty  days  is  not,  in  most  cases,  too 
long.  It  should  be  as  much  longer  as 
the  condition  of  the  skin  and  mucous 
membranes  may  indicate. 

Report    of    45     personal    cases    in 
which    children    discharged   from    the 
hospital     as    fully    cured    of    scarlet 
fever,  the  forty-second  day,  infected 
other  members  in  the  home  to  which 
they  returned.     In   6  cases   the   chil- 
dren gave  the  infection  in  four  days 
to  other  children  after  their  return; 
in  some  others  the  interval  was  from 
five   to   twenty-five    days,   but    in    the 
majority  it  averaged  seven.     It  is  still 
a    question    how    long    a    child    with 
scarlet  fever  should  be  isolated.    The 
present  six  weeks'  rule  is  inadequate. 
The  best  plan  would  be  to  have  spe- 
cial  convalescent  homes   for  children 
with     scarlet     fever     and     diphtheria. 
Baginsky    (Deut.    med.    Woch.,    Apr. 
18.  1912). 
PATHOLOGY. — In  uncomplicated 
scarlet  fever  the  lesions  are  confined 
to  the  skin  and  throat.    The  lesions  of 
the  skin  are  those  of  acute  dermatitis. 
The  papillae  and  the  stratum  beneath 

become  infiltrated  with  fluid,  while 
about  the  blood-vessels  there  are 
aggregations  of  leucocytes.  The  pro- 
duction of  epithelium  is  greatly  in- 
creased during  the  acute  stages,  which 
result  later  in  profuse  exfoliation  of 
the  superficial  layers.  In  the  later 
stages  in  addition  to  this,  according 
to  Neumann,  there  is  also  a  profuse 
development  of  exudative  cells,  par- 
ticularly among  the  ducts  and  fol- 
licles. These  cells  easily  reach  the 
epithelial  surface :  a  fact  which  ac- 
counts for  the  great  infectiousness  of 
the  desquamating  cells. 

The  throat  changes  in  uncompli- 
cated scarlet  fever  are  catarrhal  in 
nature,  and  are  an  essential  part  of 
the  disease.  The  croupous  and  diph- 
theritic membranes  must  be  consid- 
ered as  complications.  The  patho- 
logical changes  in  the  tongue  are 
similar  to  those  in  the  skin. 

Complications  and  Sequelae. — An- 
gina.— Except  in  a  very  few  mild 
cases,  the  throat  always  shows  some 
pathological  change.  A  catarrhal 
condition  of  the  throat  is  normal  to 
scarlet  fever,  but  membranous  exu- 
dates and  gangrene  are  not  essential 
to  it. 

The  true  nature  of  the  membranous 
inflammation  seen  in  scarlet  fever  was 
long  a  subject  of  discussion,  which 
has  been  settled  by  the  bacteriologist. 
With  few  exceptions,  the  angina  of 
the  early  stages  is  pseudodiphtheria, 
that  of  the  late  stages  true  diphtheria. 
While  primary  pseudodiphtheria  is  a 
mild  disease,  the  death  rate  being 
rarely  over  5  per  cent.,  secondary 
pseudodiphtheria  is  very  dangerous 
and  fatal.  The  membrane  may  ap- 
pear on  the  throat  on  the  first  or 
second  day,  but  it  is  not  usually  seen 
before  the  third  day.     It  is  generally 



confined  to  the  tonsils,  but  frequently 
nils  the  throat  and  nasopharynx.  It 
shows  a  tendency  to  invade  the  ears 
and  nose  and  to  shun  the  larynx.  It 
reaches  its  height  about  the  sixth 
or  seventh  day.  It  frequently  pre- 
sents all  the  local  characteristics  of 
diphtheria  together  w^ith  the  general 
symptoms  of  septicemia.  The  excit- 
ing cause  of  this  membranous  inflam- 
mation  is  the  Streptococcus  pyogenes. 
It  is  occasionally  associated  with  the 
Staphylococcus  aureus  or  alhus,  but  the 
streptococcus  is  the  more  commonly 
observed.  It  occurs  not  only  in  the 
pseudomembrane  and  the  tissues 
underneath  it,  but  is  found  in  the 
blood  in  large  numbers.  Through  the 
agency  of  the  toxins  which  it  gener- 
ates it  is  unquestionably  the  cause  of 
the  complications  and  general  sep- 
ticemia. The  pseudomembranes  which 
appear  late  in  the  disease  are  usually 
associated  with  the  Klebs-Loffler 
bacillus.  Diphtheria  is,  in  the  fullest 
sense  of  the  word,  a  complication,  and 
is  not  an  essential  symptom  of  scar- 
let fever. 

Otitis,  next  to  angina,  is  the  most 
common  complication,  and  in  its  re- 
sults is  one  of  the  most  serious,  as  it 
is  a  common  cause  of  deaf-mutism. 
It  results  from  extension  of  the  in- 
flammation from  the  throat  through 
the  Eustachian  tubes.  The  tendency 
to  ear  involvement  varies  in  different 
epidemics,  but  it  is  more  common  in 
young  patients.  It  does  not  usually 
occur  until  the  second  week,  and,  as 
a  rule,  involves  both  ears.  Its  pres- 
ence may  be  indicated  by  earache  and 
an  increase  in  the  fever,  but  fre- 
quently a  discharge  is  the  first  indica- 
tion that  the  ears  are  involved.  The 
process  is  prone  to  be  a  destructive 
one  and  to  result  in   long-continued 

suppuration.  It  sometimes  leads  to  a 
lapidly  fatal  meningitis. 

Adenitis  and  cellulitis  are  com- 
mon results  of  streptococcic  invasion 
of  the  throat.  Not  only  are  the 
lymphatic  glands  themselves  enlarged, 
but  there  is  more  or  less  inflammatory 
edema  of  the  surrounding  tissues. 
That  this  is  due  to  secondary  infection 
is  shown  by  the  fact  that  streptococci 
are  found  in  abundance  in  both  the 
nodes  and  edematous  tissues  around 
them.  Enlargement  of  the  nodes  may 
be  detected  during  the  first  week,  but 
serious  cellulitis  does  not,  as  a  rule, 
occur  until  later  in  the  disease.  Sup- 
puration, sloughing,  or  even  gangrene 
may  occur. 

Joint  Lesions. — Although  acute  ar- 
ticular rheumatism  sometimes  occurs, 
the  joint  affection  often  called  scar- 
latinal  rheumatism  is,  in  most  in- 
stances, a  synovitis.  It  is  mild,  and  is 
frequently  confined  to  the  wrist.  It 
appears  early  in  the  second  week,  con- 
tinues for  three  or  four  days,  and  dis- 
appears, suppuration  being  rare.  It 
is  seldom  seen  under  4  years.  Pyemic 
arthritis  occurs  in  extremely  rare  in- 
stances, and  affects  the  larger  joints, 
the  lesions  being  multiple.  Marsden 
has  recently  offered  the  following 
excellent  classification  of  the  scar- 
latinal joint  lesion:  (a)  synovitis,  {b) 
acute  or  chronic  pyemia,  (c)  acute  or 
subacute  rheumatism,  and  (d)  scrof- 
ulous disease  of  the   joints. 

Nephritis. — Albumin  may  be  found 
m  the  urine  during  the  acute  stage ; 
but  it  is  fel)rile  albuminuria,  due  to 
degenerative  nephritis,  which  sub- 
sides as  the  temperature  falls.  In  the 
grave  type  kidney  lesions  may  occur, 
to  which  the  term  septic  nephritis  has 
been  given.  The  urine  contains  albu- 
min,   but    blood    and    casts    are    not 



necessarily  present,  neither  do  the 
rational  symptoms  of  uremia  appear. 

The  most  characteristic  and  com- 
mon kidney  lesion  is  postscorlatinal 
nephritis,  and  is  a  diffuse  nephritis. 
It  develops  during-  the  third  or  fourth 
week,  and  may  follow  a  severe  or  mild 
attack.  There  may  be  no  interval  of 
apyrexia  between  the  kidney  attack 
and  the  onset  of  the  nephritis.  It 
may  be  so  mild  as  to  almost  escape 
notice,  or  it  may  be  so  severe  as  to 
cause  speedy  death.  Recovery  may 
be  complete  or  incomplete.  The  first 
symptom  to  be  noticed  is  usually 
edema  of  the  face,  which  is  frequently 
accompanied  by  feverishness  and  rest- 
lessness. Dropsy  and  all  the  charac- 
teristic symptoms  of  acute. nephritis 
rapidly  develop.  The  urine  usually 
shows  a  small  amount  of  albumin  for 
a  few  days  before  the  advent  of  defi- 
nite symptoms.  As  the  disease  de- 
velops, the  urine  becomes  scanty  and 
high  colored,  and  may  be  completely 
suppressed.  It  contains  a  large 
amount  of  albumin,  and  is  loaded  with 
blood-cells  and  casts.  The  first  evi- 
dence of  albumin  after  the  second 
week  should  be  a  warning  of  dan- 
ger, and  should  receive  immediate 

Pneumonia,  although  commonly 
found  at  the  autopsy  in  patients  who 
have  died  with  septic  symptoms,  is 
frequently  not  recognized  before 
death.  Endocarditis  and  pericarditis, 
though  uncommon,  are  sometimes  en- 
countered. Murmurs  are  occasionally 
heard  during  th^  course  of  the  disease, 
which  disappear  as  the  active  symp- 
toms subside.  Permanent  organic 
lesions  sometimes  develop  in  conjunc- 
tion with  the  late  kidney  complica- 
tions. Nervous  symptoms  are  rare. 
The    various    serous    membranes    are 

occasionally  involved.  Peculiar  at- 
tacks of  symmetrical,  superficial  gan- 
grene have  been  reported.  The  dis- 
ease may  be  complicated  by  any  of 
the  other  infectious  diseases. 

Second  attacks  of  scarlet  fever  are 
extremely  rare.  They  sometimes  oc- 
cur, but  in  most  supposed  cases  there 
has  been  some  error  in  diagnosis. 
Relapses  are  more  common  than 
second  attacks.  They  result  from 
autoinfection,  and  usually  occur  dur- 
ing the  second  or  third  weeks. 

The  writer  has  met  180  return 
cases  infected  by  145  scarlet-fever 
patients  dismissed  from  the  hospital 
as  completely  cured  and  disinfected. 
The  period  of  incubation  of  the  re- 
turn cases  was  from  three  to  fifteen 
days  in  80  per  cent,  and  from  fifteen 
to  twenty-five  in  the  remainder.  Of 
the  4178  cases  of  scarlet  fever  de- 
clared during  the  year  in  question, 
2392  were  treated  in  the  hospital  in 
his  charge.  None  of  the  adults  gave 
occasion  for  the  return  cases;  they 
occurred  with  children  who  were 
much  embraced  and  petted.  Preisicn 
(Berl.  klin.  Woch.,  June  21,  1909). 

PROGNOSIS.— The  younger  the 
patient,  the  greater  the  mortality. 
Holt,  after  the  study  of  a  large  num- 
ber of  American  and  European  cases, 
concludes  that  the  general  mortality 
may  be  assumed  to  be  from  12  to  14 
per  cent.,  while  under  5  years  it  is 
from  20  to  30  per  cent.  It  is  much 
lower  in  private  practice  than  in  hos- 
pitals. The  majority  of  fatal  cases 
occurs    in    children    under    7    years. 

The  prognosis  depends  upon:  1. 
Amount  of  poison  that  has  been  ab- 
sorbed. 2.  Whether  the  child  is  weak 
and  delicate  or  strong  and  robust.  3. 
The  occurrence  of  complications, 
especially  cardiac,  pulmonary,  renal, 
and  otitic.  Very  high  temperature 
indicates  a  bad  prognosis.  The 
younger  the  child  the  graver  the  prog- 



nosis.  Mortality  is  estimated  at  from 
20  per  cent,  to  30  per  cent,  in  children 
under  5  years  of  age.  Causes  of 
death:  L  Scarlatinal  toxemia.  2. 
Nephritis.  3.  Brain  abscess  from  ex- 
tension. H.  Brooker  Mills  (Therap. 
Gaz.,   May,   1921). 

Prognosis  becomes  unfavorable  on 
the  appearance  of  the  following  symp- 
toms, the  gravity  being  in  propor- 
tion to  their  severity  :  Violent  onset, 
high  temperatures,  convulsions,  ex- 
tensive pseudomembranous  or  gan- 
grenous pharyngitis,  diphtheria, 
croup,  pneumonia,  extensive  cellulitis, 
superficial  gangrene,  nephritis,  and 
exhaustion  with  general  septic  symp- 
toms. The  prognosis  in  uncompli- 
cated cases  is  good. 

Sudden  death  is  not  uncommon  in 
this  disease,  and  is  usually  due  to 
myocardial  trouble.  Weill  and  Mouri- 
quand   (Presse  med.,  Aug.  5,   1911). 

Morbidity  of  over  7,000,000  cases 
collected  and  studied  from  communi- 
ties in  America,  Europe  and  else- 
where. The  most  striking  fact  about 
case-fatality  of  scarlet  fever  in  the 
past  half-century  has  been  its  con- 
sistent, general  and  marked  reduc- 
tion. The  sexes,  as  a  whole,  show 
about  equal  susceptibility.  During 
the  first  five  years  of  life  males  are 
more  susceptible  to  the  disease,  while 
between  5  and  15  years  females  are 
distinctly  more  susceptible.  Case- 
fatality  is  higher  among  males  at  all 
ages.  Nearly  half  of  the  scarlet  fever 
cases  was  found  to  occur  in  the  five 
years  between  3  and  8  years  of  age, 
distributed  nearly  equally  in  each  of 
the  five  years,  and  2  children  out  of 
3  at  this  age  contract  the  disease, 
when  exposed  to  it  in  their  homes. 
Ninety  per  cent,  of  cases  occur  un- 
der 15  years  of  age.  Mortality  is 
highest  in  infancy,  being  from  12  to 
20  per  cent.;  lowest  at  about  10  years 
of  age,  and  thereafter  gradually  in- 
creases with  age.  About  90  per 
cent,  of  deaths  occur  under  10  years 

of     age.       H.     H.     Donnally     (Wash. 
Med.   Annals,   Nov.,    1915). 

PROPHYLAXIS.— In  view  of  the 
gravity  of  the  disease  and  the  efifect- 
iveness  of  preventive  measures,  pro- 
phylaxis assumes  unusual  importance. 
The  most  important  of  all  prophylac- 
tic measures  is  complete  isolation  of 
the  sick.  This  applies  to  nurse  as 
well  as  to  patient.  If  possible,  one 
'person  should  be  selected  as  an  inter- 
mediary between  the  nurse  and  the 
family.  The  doctor  should  always 
wear,  in  the  sick-room,  a  gown  of 
muslin  or  calico  fastened  at  the  neck 
and  waist,  and  long  enough  to  com- 
pletely cover  his  clothes.  A  stetho- 
scope should  be  used  in  making  phys- 
ical examinations  of  the  chest. 

The  period  of  isolation  should  not 
be  less  than  forty  days  and  as  much 
longer  as  the  presence  of  desquama- 
tion or  purulent  discharges  may  de- 

The  best  prophylactic  treatment  is 

the  removal  of  enlarged  and  diseased 

adenoids  and  tonsils. 

Scarlet  fever  having  appeared  in  2 
pupils  in  a  school  of  over  300,  the 
2  patients  were  at  once  isolated  and 
the  throats  of  all  the  contacts  sprayed 
with  a  1 :  2000  solution  of  mercury 
perchloride.  No  other  cases  ap- 
peared, and  the  remaining  children 
appeared  in  perfect  health,  save  for 
the  fact  that  in  131  cases  out  of  the 
remaining  299  an  elevation  of  tem- 
perature varying  between  99°  and 
101°  F.  (37.2°  and  38.3°  C),  and  last- 
ing for  two  or  three  days,  was  found. 
There  were  absolutely  no  other 
symptoms  or  indications  of  the  chil- 
dren being  out  of  sorts.  Thornton 
(Brit.  Med.  Jour.,  Feb.  29,  1908). 

In  the  last  28  years  4251  cases  of 
scarlet  fever  have  been  reported  at 
Brunn.  Sterilization  of  the  premises 
and  measures  to  prevent  infection  of 
others    failed    in    a    large    number    of 



cases.  It  is  evident  that  the  virus  is 
transmitted  not  only  in  the  period 
of  incubation,  but  long  after  recov- 
ery, far  beyond  the  routine  six 
weeks.  The  aim  should  be  to  re- 
move the  virus  from  tlie  mouth  by 
mechanical  means.  Kokall  (Wiener 
klin.  Woch.,  Dec.  29,  1910). 

Numerous  observers  of  late,  espe- 
cially in  England,  have  shown  that 
by  the  cleansing  treatment  of  nose 
and  throat  with  a  mild  antiseptic 
healthy  children  could  be  kept  in  con- 
tact with  children  ill  with  scarlatina 
without  contracting  the  disease.  The 
writer  has  treated  2  families,  6  chil- 
dren in  each  family,  where  one  mem- 
ber had  contracted  scarlatina,  and  by 
the  simple  process  of  cleaning  the 
nose  and  throat  three  times  a  day  for 
six  weeks  he  has  prevented  any  fur- 
ther spread  of  the  disease.  Schultze 
(Med.  Rec,  Dec.   10,   1910). 

Dischargees  from  the  patient  should 
be  disinfected  with  strong  subHmate 
sokitions.  The  bedding,  carpet,  and 
clothinp-  should  be  disinfected  with 
boiling  water  or  steam.  The  mat- 
tress should  be  destroyed.  The  room 
itself  should  be  thoroughly  washed — 
floor,  ceiling,  and  walls — with  a 
1 :  2000  sublimate  solution. 

One  room  on  the  top  floor  of  every 
house  should  be  arranged  for  a  sick- 
room :  the  moldings  should  be  plain, 
and  the  floor  of  hard  wood ;  the  walls 
and  ceilings  should  be  painted  or  cov- 
ered with  washable  paper ;  the  bed- 
stead should  be  of  enameled  iron.  It 
is  a  fallacy  to  suppose  that  dishes  in 
the  sick-room,  filled  with  antiseptic 
fluids,  can  limit  the  spread  of  the  dis- 
ease, or  that  there  is  any  efficiency,  as 
a  prophylactic,  in  generating  steam 
impregnated  with  medicinal  agents. 
The  use  of  such  agents  is  liable  to 
generate  a  false  sense  of  securitv  and 
lead  to  the  neglect  of  more  important 

[The    child    should    have    its    own 
dishes.     Everything  should  be  disin- 
fected before  it  leaves  the  room — i.e., 
sheets,      pillow-cases,      towels,      and 
everything   used    for    the    patient — in 
bichloride  of  mercury  solution   1  :500 
or    phenol    solution    1:50;    also    the 
urine  and  feces,  which  should  be  col- 
lected in  a  bed-pan  containing  equal 
parts  chloride  of  lime  and  strong  vine- 
gar.    So  far  as  possible  use  materials 
that  can  l)e  burnt.     Diapers  could  be 
made  of  old  sheets,  and  napkins  could 
be  made  of  paper.     Hang  a  sheet  at 
the  door  and  keep  it  wet  with  either 
of   the    solutions!   mentioned,    as   this 
will  catch  the  dust  from  the  outside 
and  infected  material  from  the  inside 
of  the  room.     Sprinkle  one  of  these 
solutions  on  the  floor,  or  mop  once  or 
twice  a  day.     Have  a  gown  and  cap 
handng-  at  the  door  and  a  pair  of  rub- 
ber    overshoes    for    your    own    use. 
Take  the  tjown  off  at  the  door  of  the 
sick-room,  and  have  it  disinfected  be- 
tween   visits.      When   you    leave   the 
room,  go  to  the  bath-room  and  wash 
the  hands  and  face  in  a  weak  bichlo- 
ride solution.     The  mail  should  also 
be     carefully     disinfected     before     it 
leaves  the  house,  using  dry  heat,  and 
all  animals  kept  out  of  the  sick-room 
during  the  illness,  as  they  are  great 
carriers  of  the  infection. — H.  Brooker 

Streptococcic  vaccines  have  been 
tried.  The  most  satisfactory  of  these 
so  far  has  been  Gabritschewsky's, 
reference  to  which  has  already  been 
made  on  page  342  in  the  second  vol- 
ume of  the  present  work. 

Gabritschewsky's  vaccine  for  scarlet 
fever  is  made  from  streptococci  iso- 
lated from  the  blood  in  the  hearts  of 
children  dead  of  scarlet  fever.  It  is 
a     condensed     bouillon      culture      of 



streptococci  killed  by  heating  to  60° 
C,  and  the  addition  of  Yz  per  cent, 
carbolic  acid  solution.  Each  c.c.  con- 
tains 0.02  to  0.03  of  the  bacterial 
mass.  The  vaccine  was  first  used  in 
Moscow  in  1904.  Usually  10  drops 
were  injected  with  an  ordinary  hy- 
podermic syringe.  The  injections 
were  made  during  an  epidemic  of 
scarlet  fever,  185  persons  being  thus 
treated,  as  a  preventive  measure.  A 
rise  of  temperature  was  observed  in 
all  but  one.  A  moderate  rise  in  64 
persons,  a  faint  rise  in  54,  a  marked 
rise  in  66.  Local  tenderness  was 
seen  in  66  patients,  redness  in  the 
injected  area  in  173;  swelling  in  103. 
In  many  cases  there  was  a  rash  re- 
sembling true  scarlet  fever,  and  in  5 
patients  there  was  desquamation. 
There  was  a  general  rash  in  43  per- 
sons, a  local  rash  in  70;  no  rash  in 
72  of  the  185  patients;  only  2  devel- 
oped scarlet  fever;  the  remainder  re- 
mained well,  save  that  they  showed 
these  temporary  complications  after 
the  use  of  the  vaccine.  Schamarine 
(Roussky  Vratch,  June  30,  1907). 

The  streptococcus  vaccines,  used  as 
advocated  by  Gabritschewsky,  have 
some  influence  in  controlling  epi- 
demics of  scarlet  fever.  Their  use, 
with  proper  care,  is  attended  by  no 
harmful  results.  They  should  be 
given  a  wider  application  in  this 
country  to  prove  or  disprove  the  con- 
tentions of  the  Russian  physicians. 
Smith  (Boston  Aled.  &  Surg.  Jour., 
Feb.  24,   1910). 

After  using  the  Gabritschewsky 
vaccine  in  700  cases  the  writer  con- 
cluded that  it  had  a  decided  value 
from  a  prophylactic  standpoint.  In 
comparing  the  effects  observed  he 
states  that  but  one  very  light  case  of 
scarlet  fever  has  occurred  among  the 
nurses  who  have  received  vaccine 
treatment,  while  in  a  considerably 
smaller  group,  under  identical  condi- 
tions, 5  developed  severe  cases  of 
scarlet  fever.  Walters  (Jour.  Amer. 
Med.    Assoc,    Iviii,    546,    1912). 

During  a  severe  epidemic  of  scarlet 
fever    in    a    number    of    villages    the 

writer  used  Gabritschewsky's  bac- 
terins,  making  about  3000  inocula- 
tions. The  results  were  very  satis- 
factory. It  was  found,  however,  that 
a  single  inoculation  does  not  confer 
immunity,  and  that  immunity  does 
not  last  over  six  months.  Poloteb- 
nova  (Roussky  Vratch,  July  14, 

[A  physician  should  not  attend  an 
obstetric  case  while  in  attendance 
upon  a  patient  suffering  with  scarlet 
fever. — H.  Brooker  Mills.] 

TREATMENT.— Many  specifics 
for  scarlet  fever  have  been  proposed, 
tried,  and  found  wanting.  Much  may 
be  done  to  avert  complications  and  to 
render  them  less  serious  when  they 
occur,  and  many  lives  may  be  saved 
by  judicious  management.  Mild  cases 
require  little  or  no  medication ;  they 
usually  receive  too  much. 

The  patient  should  be  kept  in  bed 
for  at  least  three  weeks,  and  should 
receive  a  fluid  diet  for  not  less  than 
two  weeks.  Milk  is  the  best  diet  for 
scarlet-fever  patients.  It  may  be 
given  peptonized  or  plain.  Later  in 
the  disease  broths,  eggs,  or  meat- 
jellies  may  be  given.  The  stoinach 
should  never  be  overfilled. 

[The  diet  should  be  liquid  and 
nourishing.  If  the  child  is  breast-fed, 
have  the  milk  pumped  from  the  breast 
and  fed  to  the  child.  If  a  bottle  baby, 
dilute  one-half  with  water  if  on 
straight  milk,  because  whole  milk 
constipates  and  causes  tympanites,  or 
give  half  milk  and  half  Vichy  water, 
because  alkalies  help  to  neutralize  the 
acidity,  which  is  one  of  the  causes  of 
the  nei:)hritis.  Orange  juice  is  very 
beneficial.  Lemonade  is  good,  espe- 
cially if  one  adds  to  every  pint  (500 
c.c.)  1  dram  (4  Gm.)  of  cream  of  tar- 
tar. Cereals  may  be  cautiously  added, 
and    water    should    be    given    freely. 


Avoid    the    use    of    salt    and    exclude  The   throat   symptoms  of  the   first 

soups  and  bouillon   from  the  diet. —  few  days  may  be  mitif^^ated  by  giving- 

H.  Brooker  Mills.]  cool  water  or  bits  of  ice.     Later  hot 

The    initial    vomiting    usually    re-  drinks  may  be  given  or  irrigation  of 

quires  no  treatment,  ]:)ut  the  bowels  the  back  of  the  throat  with   a  weak 

should  be  acted  upon  mildly  by  small,  hot  saline  or  boric  acid  solution  may 

repeated    doses    of    calomel.       Later  be    employed.      Chlorate    of    potash 

they  should  be  kept  acting,  if  possible,  should    l)e    avoided.       Its    beneficial 

by  means  of  enemata  rather  than  by  efifects  are  doubtful.    Nasal  syringing 

the  use  of  cathartic  drugs.  should  be  avoided  unless  clearly   in- 

In  severe  cases  stimulants  are  re-  dicated  by  a  purulent  nasal  discharge 
quired.  In  malignant  cases  they  or  obstruction  of  the  nasopharynx, 
should  be  pushed  to  the  point  of  More  harm  than  good  may  result  from 
tolerance.  Strychnine  is  of  great  overzealous  attempts  at  local  treat- 
value  in  septic  cases  with  prostration ;  ment  of  the  throat  and  nose.  The 
it  may  often  be  combined  to  advan-  most  successful  treatment  consists  in 
tage  with  digitalis.  Bathing  the  sur-  the  use,  not  of  active  and  poisonous 
face  with  warm  water  followed  by  antiseptics,  but  of  mild  and  cleansing 
anointing  with  plain  or  carbolic  vase-  washes,  freely  and  frequently  applied. 
lin  or  a  5  per  cent,  ichthyol  ointment  [As  to  the  toilet  of  the  nose  and 
should  be  begun  as  soon  as  the  first  throat:  Swab,  spray,  or  gargle  with 
signs  of  desquamation  appear,  and  alkaline  solution,  according  to  the  age 
should  be  continued  throughout  the  of  the  child.  If  the  patient  be  old 
course  of  the  disease.  enough  to  gargle,  this  should  be 
For  the  itching,  which  is  sometimes  done ;  if,  on  the  other  hand,  it  be  too 
intolerable,  keeping  the  .child  restless  young  for  that,  but  old  enough  to 
and  irritable,   the  writer   finds  spong-  opg^  J^S  mouth  and  put  out  its  tongue 

ing  the   body   with   a  warm   solution  i ^.    u    *.      j  ,i  i  i  • 

,       ,.             u       .     /       •           .-  when   told   to   do   so,   then   swabbmg 

of   sodium   carbonate    (gram    x — Gm.  i          i        ,  •,       . 

0.6-to-5j-60  c.c),  to  which  a  little  "^''^y  ^'^  employed,  while,  if  it  be  too 

mucilage  has  been  added,  very  useful  young   to   do   this,    spraying  with   an 

and  soothing.    Seymour  Taylor  (Med.  atomizer  would  be  better.     Potassium 

Bull.,  Aug.,  1907).  permanganate,     gr.     ss     (0.03     Gm.), 

Tepid  baths  (28°  to  32°  C.-82.4°  to  ^^ter  f,j    (30  c.c),  is  a  good  solution 

89.6°   F.)  of  20  minutes'  duration  and  ,                r          .•                 it-, 

.,  to  use  lour  times  a  day.     Do  not  use 

given   every   evening,   or  it  necessary,  .            ,  , 

morning  and  evening,   will  often   in-  Potassium  chlorate  for  the  sore  throat, 

duce    sufficient    sedation.      The    un-  because   of   its   well-known   irritating 

pleasant  sensation  of  heat  in  the  skin  effect  on  the  kidneys  should  any  of  it 

is  also  allayed  by  such  baths,  though  be    swallowed    or    absorbed.       After 

still     more     effectually     by     rubbings       .,^; .i         ii     i-  i    i.-        •      --i      r 

.,,     r •  using  the  alkaline  solution  instil  a  few 

with  the  following  liniment: —  ,            .            ,               •■,     .              ., 

■drops  m  each  nostril  of  anv  oily  prep- 

Cold  cream,              _  aration,  such  as :- 

Neutral  glycerin aa  50  Gm.  (12 'jr). 

M.      Ft.   linimentum.  ^  Menthol    gr.  x   (0.65  Gm.). 

The  liniment  should  preferably  be  '^''^"'^^  ''^^ &''•  'J   ^^-^^  Gm.). 

used      luke-warm.        A.      F.      Plicque  01.  eucalypt fSss  (2.0  c.c). 

(Med.   Bull.;    N.   Y.   Med.   Jour.,  July  Liq.  albolem  ....q.  s.  fSij   (60  c.c). 

27,  1912).  H.  Brooker  Mills.] 



Adenitis  can  only  be  controlled  by 
checking  the  septic  process  at  its 
fountain-head  in  the  throat.  The  ap- 
plication of  hot  oil  or  the  hot-water 
bag  is  soothing  to  some  patients,  but 
the  use  of  cold  is  preferable  in  most 
cases.  Poultices  should  not  be  ap- 
plied continuously.  Diffuse  suppura- 
tion requires  free  incision.  Otitis  re- 
quires the  treatment  demanded  by  the 
disease  in  other  conditions.  The 
joint  affections  require  but  little  treat- 
ment other  than  rest  and  protection. 
Rheumatism  should  receive  its  own 
appropriate  treatment.  Restlessness 
and  nervous  symptoms  are  sometimes 
relieved  by  cold  to  the  head,  or  by  the 
use  of  small  doses  of  phenacetin,  not 
enough  being  given  to  materially 
affect  the  temperature.  Nephritis 
should  receive  prompt  and  very  care- 
ful attention.  Tts  treatment  is  that  of 
nephritis  due  to  other  causes. 

A  study  of  325  cases,  with  23 
deaths,  in  the  Alexandra  Hospital, 
Montreal,  showed  that  twenty-one 
days'  milk  diet  and  twenty-one  days' 
bed  should  be  the  rule  to  prevent 
death  from  nephritis  J.  McCrae 
(Montreal   Med.  Jour,   Sept.,    1908). 

The  temperature  may  require  atten- 
tion from  the  outset,  but  it  should 
not  be  forgotten  that  a  high  tempera- 
ture IS  normal  to  scarlet  fever.  It 
may  be  allowed  to  run,  therefore, 
without  interference,  to  a  somewhat 
higher  point  than  in  most  other  dis- 
eases. Hyperpyrexia,  or  a  tempera- 
ture continuously  above  104°  F. 
(40°  C),  demands  treatment.  It  is 
best  reduced  by  means  of  the  cold 
bath;  l)Ut  this,  for  obvious  reasons,  is 
less  practical  in  private  than  in  hos- 
pital practice.  The  cold  pack  or  cold 
sponging  are  more  available.  An 
effective    method    of    applying    cold 

adopted  at  the  Willard  Parker  Hos- 
pital IS  thus  described  by  Northrup: 
"The  tendency  in  all  cooling  processes 
is  for  the  feet  to  become  cold.  To 
obviate  this  the  patient  is  placed  upon 
blankets,  but  the  legs,  feet,  arms,  and 
hands  are  wrapped  in  warm,  dry 
blankets,  and  hot  bottles  are  inclosed 
in  the  wrappings.  An  ice-bag  is  ap- 
plied to  the  head.  The  face  and 
trunk  are  freely  sponged  in  wann 
water  and  alcohol,  evaporation  being 
hastened  by  fanning,  so  long  as  it 
cools  the  patient,  clears  the  cerebrum, 
gives  force  and  improved  rhythm  to 
the  heart,  and  leaves  the  patient  to  a 
quiet  sleep." 

Great  caution  should  be  exercised 
in  the  use  of  antipyretic  drugs.  No 
coal-tar  antipyretics  should  be  used. 

[Treat  the  temperature  hydrothera- 
ipeutically — i.e.,  sponge  baths,  colonic 
irrigations,  ice-bags,  etc.  In  cases  of 
very  high  temperature,  and  especially 
with  diminution  of  urine,  once  a  day 
wrap  the  child  in  a  blanket  and  place 
it  in  water  at  a  temperature  of  90°  to 
95°  ;  keep  it  there  for  from  10  to  12 
minutes ;  take  out  of  wet  blanket  and 
place  in  dry  blanket,  and  give  inunc- 
tion of  cacao  butter.  Try  to  have  two 
rooms,  one  for  day  and  one  for  night, 
preferably  with  a  sunshine  exposure. 
Keep  temperature  of  rooms  at  68°  to 
70°    F.— H.  Brooker  Mills.] 

In  all  cases  in  which  hypodermic 
injections  of  large  doses  of  quinine 
bihydrochloride  were  given  the  infec- 
tion was  cut  short.  The  fever  yielded 
after  the  second  or  third  injection, 
desquamation  rapidly  supervened,  and 
prompt  recovery  followed.  A.  Tram- 
busti  (Semaine  med.,  June  18,  1913). 
The  writer  uses  quinine  bihydro- 
chloride, giving  a  30  per  cent,  solu- 
tion hypodermically  in  full  doses.  A 
single  injection  is  said  to  reduce  the 
temperature    rapidly   and   to   improve 



the     subsequent     course.       Chichkine 
(Gac.    Med.   Catalan.,  Jan.,   1915). 

Serum  treatment  has  been  tested 
very  extensively,  but  1  feel  con- 
strained to  say  that  up  to  the  present 
time  it  has  not  proved  of  the  value 
hoped  for.  It  is  certain  that  the  stock 
antistreptococcus  serums  have  not 
shown  themselves  to  be  of  striking 
value.  Decided  results  have  been 
claimed  for  Escherich  and  ]\Ioser's 
serum,  but  it  has  not  been  generally 
adopted.  Inasmuch  as  the  more 
serious  symptoms  of  scarlet  fever  are 
all  largely  due  to  streptococcic  infec- 
tion, the  theory  underlying  the  use  of 
normal  serum  is  not  irrational.  At 
the  present  writing,  however,  no  posi- 
tive statements  can  be  made  regard- 
ing its  efificacy. 

[The  value  of  antistreptococci 
serum  is  doubted  and  its  use  is 
limited.  There  are  several  conditions 
where  one  would  not  use  the  serum : 
1.  In  cases  with  very  high  tempera- 
ture. 2.  In  very  young  infants  or  pa- 
tients who  are  greatly  exhausted  from 
the  effects  of  the  disease.  If  indi- 
cated, use  20  to  40  c.c.  every  4  to  6 
hours.  The  prophylactic  dose  to 
others  is  10  c.c,  but  a  single  inocula- 
tion does  not  confer  immunity,  and 
immunity,  when  present,  does  not  last 
over  6  months. — H.  Brooker  Mills.] 

More  promising  results  have  been 
obtained  from  serum  of  convalescents. 
In  a  recent  malignant  epidemic  of 
scarlatina  at  Stockholm,  convalescent 
serum  was  obtained  from  the  fourth 
to  the  seventh  week  of  the  disease, 
and  0.5  per  cent,  of  phenol  added.  It 
was  then  used  exclusively  in  des- 
perate cases,  with  intense  intoxica- 
tion, bad  mental  state,  pulse  140  to 
160,  cyanosis,  fever  40°  to  41°  C— 
cases  in  which  recovery  would  aver- 
age much  less  than  50  per  cent.  Of 
237    cases    sufficiently    serious    to    re- 

ceive serum,  195  recovered,  while  25 
died  in  the  first  and  17  in  the  second 
week  of  the  disease.  Of  the  195 
cures,  101  were  very  prompt.  In  91 
cases  of  the  same  type  who  received 
no  serum  the  mortality  was  70  per 
cent.  Mild  cases  can  supply  serum 
as  potent  as  severe  cases.  Kling  and 
Widfelt   (Hygiea,  Jan.    16,    1918). 

In  treating  severe  scarlet  fever 
witli  convalescent  serum,  the  blood 
was  drawn  from  the  twentieth  to  the 
twentj--eighth  day.  Serums  from  sev- 
eral patients  were  mixed,  tested  for 
sterility,  and  stored  in  the  refriger- 
ator. The  serum  was  injected  intra- 
muscularly in  the  thighs  in  doses  of 
25  to  90  c.c.  (6%  drams  to  3  ounces), 
60  c.c.  (2  ounces)  being  tlie  usual 
dose.  Commonh'  a  single  dose  was 
given,  occasionally  2.  Xo  local  or 
general  disturbances  followed.  Nine- 
teen cases  were  thus  treated.  Quite 
constantly  a  fall  of  temperature  be- 
gan two  to  four  hours  after  the  in- 
jection and  continued  gradually  for 
twelve  to  twent}--four  hours.  In 
purth-  toxic  cases  the  temperature 
fell  to  nearly  normal  and  tended  to 
remain  there.  In  cases  with  septic 
complications  it  rose  again  after  the 
fall  and  ran  a  "septic"  course.  Weaver 
(Jour,  of  Infect.  Dis.,  Mar.,  1918). 

Report  of  favorable  results  in  pro- 
phylaxis of  scarlet  fever  by  the  use 
of  a  sere  vaccine  obtained  from  the 
desquamated  scales  of  scarlet  fever 
patients.  Horses  treated  with  it  de- 
veloped antibodies  in  their  serum  to 
an  amboceptor  power  of  2000.  Of  40 
children  immunized  and  allowed  to 
live  and  sleep  in  the  same  bed  with 
scarlet  fever  patients,  not  one  con- 
tracted the  disease.  Of  25  children  in 
families  where  there  was  a  case  of 
the  disease,  not  one  contracted  it. 
The  immunized  children  were  fol- 
lowed for  si.x  months,  and  the  per- 
sistent presence  of  the  amboceptors 
confirmed.  Di  Cristina  and  Pastore 
(Pediatria,  Jan.,  1919). 

According  to  Ramond  and  Schultz, 
sodium  salicylate  possesses  to  a  cer- 
tain degree  specific  properties. 



Sodium  salicylate  is  indicated  in 
scarlatina.  It  should  be  given  from  the 
start,  but  on  the  fifth  day  discontin- 
ued, and  resumed  from  the  fifteenth 
to  the  twentieth  day,  when  late  com- 
plications are  due.  The  dose  is  about 
6  Gm.  (90  grains)  per  day,  increased 
to  8  Gm.  (2  drams)  or  more  if  re- 
quired. Nocturnal  exacerbations  be- 
ing typical  in  scarlet  fever,  the  drug 
should  be  continued  during  the  night. 
At  the  fifteenth  day  the  dosage  need 
not  be  as  large.  Under  this  drug  the 
fever  subsides  by  the  third  day.  The 
throat  lesions  are  rapidly  reduced,  but 
with  the  recrudescence  at  the  fifteenth 
day,  may  reappear  in  an  aggravated 
form.  They  are  rapidly  controlled  by 
the  salicylate.  The  latter  may  abort 
late  nephritis  if  given  in  time,  but  if 
the  complication  has  several  days' 
headway,  should  be  given  cautiously, 
lest  the  kidneys  be  unable  to  excrete 
it.  If  it  can  pass  the  kidneys  the  dose 
may  then  be  augmented.  On  all  other 
manifestations  of  the  disease,  the 
drug  acts  more  or  less  as  a  specific. 
Ramond  and  Schultz  (Jour,  de  med. 
de  Paris,  Sept.,  1916). 

Salvarsan,  and  especially  neosal- 
varsan,  have  been  much  lauded,  but 
neither  has  stood  the  test  of  experience. 

[But  little  medicine  should  be 
given,  but  the  free  use  of  water  is 
necessary.  The  one  and  only  drug" 
that  is  usually  necessary  is  potas- 
sium citrate  in  2-  to  5-  grain  (0.13  to 
2  Gm.)  doses,  or  liquor  potassii 
citratis,  15  to  20  minims  (0.9  to  1.25 
c.c.)  three  times  a  day.  Sweet  spirit 
of  nitre  should  not  be  given  freely. 
The  skin  in  scarlet  fever  is  not  active, 
and  therefore  there  is  no  use  for  a 
diaphoretic  ;  as  for  diuretics,  the  pos- 
sibility of  damaged  kidneys  should 
always  be  borne  in  mind.  If  renal 
inflammation  develops,  poultices  ap- 
plied over  the  kidney  region  may  do 
good.  Make  flaxseed  poultice  with  16 
parts  flaxseed  and  1  part  mustard,  or 

4  parts  flaxseed  and  1  part  digitalis 
leaves.  Put  on  every  four  hours  dur- 
ing the  day,  and  keep  on  hot  for  half 
an  hour.  For  stimulation,  when 
needed,  caffeine  sodium-benzoate  in 
%-grain  (0.03  Gm.)  doses  hypoder- 
inically  is  among  the  best.  Digitalis 
and  strophanthus,  the  latter  especially 
in  very  young  children,  may  be  em- 
ployed by  mouth.  Itching  is  very 
troublesome  during  desquamation  in 
scarlet  fever;  warm  baths  followed 
by  cacao-butter  inunctions  are  very 
helpful.— H.  Brooker  Mills.] 

As  emaciation  and  anemia  are  fre- 
quent results  of  scarlet  fever,  active 
tonic  treatment  should  be  instituted 
during  the  convalescence,  the  chief  re- 
liance being  placed  upon  iron.  Bash- 
am's  mixture  is  especially  indicated. 
The  patient  should  be  particularly 
protected  from  cold,  for  exposure  not 
infrequently  seems  to  precipitate 
nephritis  long  after  its  usual  period  of 

When  the  depression  becomes 
threatening  the  use  of  adrenalin 
sometimes  proves  very  beneficial,  as 
shown  by  Hutinel.  The  1 :  1(X)0  solu- 
tion may  be  slowly  injected  intra- 
muscularly in  saline  solution,  the  dose 
varying  with  the  age,  from  5  to  10 
minims,  repeated  every  hour  or  two. 

The  blood-pressure  was  found  in  a 
series  of  cases  to  be  subnormal  in  25 
per  cent.  Pronounced  arterial  hy- 
potension, especially  if  accompanied 
by  other  signs  of  acute  suprarenal 
insufficiency,  should  be  treated  by 
adrenalin.  J.  D.  Rolleston  (Brit. 
Jour,  of  Children's  Dis.,  Oct.,  1912). 

The  writer  found  adrenalin  very 
useful  in  tiding  the  patients  past  the 
danger  point  when  the  adrenals 
seemed  to  be  suffering  acutely  from 
the  infectious  toxic  process.  Cam- 
phorated oil,  also  proved  surprisingly 
effectual.       P.     H.     Kramer     (Neder- 




landsch    Tijdschrift    v.    Geneeskunde, 
Sept.  6,   1913). 

In  the  writer's  service  there  were 
34  cases  of  malignant  scarlet  fever 
in  a  total  of  550  cases  of  this  disease; 
in  a  previous  series  of  833  cases  there 
were  27  that  terminated  fatally.  Re- 
covery was  the  rule  in  destructive 
lesions  in  the  throat;  the  defects  in 
the  tissues  were  filled  in  time  and  no 
operation  was  required.  Hutinel 
(Arch,  de  med.  des  cnfants,  Feb.  1915). 
Floyd  M.  Cr.and.all, 

New  York, 


H.  Brooker  Mills, 


SCHLAMMFIEBER.  -This  name 
was  applied  to  a  form  of  acute  infectious 
jaundice  which  occurred  among  young 
subjects  who  had  worked  in  the  districts 
of  Breslau  that  had  been  recently  flooded. 
It  is  not  entitled  to  classification  as  a 
disease,  since  it  corresponds  in  every  way 
with  acute  infectious  jaundice  (Weil's  dis- 
ease), treated  on  page  394  of  the  sixth 
volume  of  the  present  work. 


— A  disease  characterized  by  induration 
of  the  skin,  and  at  times  of  the  sub- 
cutaneous tissues,  which  sometimes  pro- 
gresses to  complete  atrophy  of  these 

VARIETIES.— Three  main  varieties  of 
scleroderma  are  recognized:  the  diffuse, 
which  is  generalized  or  limited  to  certain 
areas;  the  circumscribed,  or  morphea, 
which  appears  in  spots;  and  sclerodac- 
tyly,  which   is   limited   to   the   hands. 

SYMPTOMS.— In  the  diffuse  form, 
after  a  series  of  prodromic  symptoms, 
sensations  of  chilliness  or  heat,  pruritus, 
and  pain  in  the  muscles  and  articulations, 
the  tissues  becoming  thickened,  stifif,  and 
hard,  and  appear  edematous.  The  skin 
is  cold  and  whitish,  contracted,  and  some- 
times painful.  The  face  and  the  upper 
part  of  the  body  may  be  the  only  parts 
aflfected,  but  the  entire  body  becomes  in- 
volved. The  skin  is,  as  it  were,  glued  to 
the  skeleton,  the  fingers  and  toes  being 
thin  and  stifif  or  hooked.  A  variable 
amount  of  pigmentation  is  usually  pres- 
ent   in    well-developed    cases.      Gangrene 

is  sometimes  observed,  constituting  the 
mutilating    form. 

In  the  circumscribed  variety,  the  mor- 
phea of  Erasmus  Wilson,  the  affected 
spots  are  limited  in  area,  the  spots  being 
flat  or  raised,  oval  or  rounded.  Their 
color  varies  from  a  light  pink  to  a  pale 
or  dark  violet,  and  undergoes  changes 
which  ultimately  give  the  lesion  a 
characteristic  aspect:  a  whitish-brown 
squamous  center  surrounded  by  a  bluish 
or  lilac  pigmented  border,  or  ring.  They 
are  seldom  painful,  though  pruritus  is 
sometimes  complained  of.  The  spots,  of 
which  there  are  generally  but  two  or 
three,  are  usually  located  upon  the  neck, 
the  chest,  the  abdomen,  the  arms,  or 
the  thighs.  These  spots  gradually  fade 
away,  but  occasionally  cicatrices  are  left 
to  mark  the  location  of  the  lesions.  The 
prognosis  in  this  form  is  favorable. 

In  sclcrodactyly  the  third  phalanx  be- 
comes atrophied  and  its  tissues,  including 
the  nail,  are  partially  destroyed  by  ab- 
scess. The  flexor  tendons  are  contracted 
and  give  the  finger  the  appearance  of  an 
angular  hook  by  flexing  the  first  phalanx 
upon  the  second.  Here  also  the  skin  is 
hard,  contracted,  adherent  to  the  bones, 
and  lilac  in  color.  The  prognosis  is 
necessarily  unfavorable,  owing  to  the 
mutilations    caused   by   the   disease. 

DIAGNOSIS.— The  only  condition  with 
which  scleroderma  can  be  easily  con- 
founded is  leprosy,  but  the  tubercles  of 
the  latter  disease,  the  broad  dissemina- 
tion of  the  skin  lesions,  the  nasal  dis- 
order, the  character  of  the  ulcerations, 
and  the  disturbances  of  sensation  usually 
facilitate    its    recognition. 

Osier  observes  that  diffuse  scleroderma 
must  sometimes  be  distinguished  from 
brawny,  solid  edema,  met  with  at  times  in 
patients  with  long-standing  renal  or  car- 
diac disease,  in  which  there  is  induration 
following  chronic  dropsy.  In  scorbutic 
sclerosis  there  may  be  parchment-like 
immobility  of  the  skin,  due  to  extensive 
subcutaneous  hemorrhages,  involving  the 

During  the  stage  of  swelling  it  may 
resemble  myxedema.  In  Raynaud's  dis- 
ease the  infiltration,  pigmentation,  and 
extreme  cyanosis  are  not  wholly  unlike 
those    of    scleroderma.      The    increase    of 



pigment  may  suggest  Addison's  disease, 
since    the    bronzing   may    be    extreme. 

Scleroderma  is  an  angiotrophoneurosis, 
most  frequently  observed  among  neurotic 
subjects  and  often  in  connection  with 
the  rheumatic  diathesis.  It  may  appear  at 
any  age,  but  chiefly  in  early  adult  life, 
and  is  more  prevalent  among  women  than 
men.  The  neurotic  influence,  however, 
does  not  account  for  all  cases,  nerve- 
changes  being  wanting  in  the  majority. 
Exposure  to  cold  and  wet,  rheumatism, 
nerve  shocks,  menstrual  disorders,  trau- 
matism,   etc.,    are    named    as    causes. 

Kaposi  notes  that  the  lesions  follow, 
to  a  degree,  vascular  distribution.  The 
morbid  changes  peculiar  to  scleroderma 
include  an  endoperiarteritis,  which  may 
be  traced  to  various  structures:  the  mus- 
cles, the  myocardium,  the  uterus,  the 
lungs,  and  the  kidneys  particularly.  The 
sclerosis  would  thus  seem  to  be  a  result 
of  the  vascular  disturbances,  through 
impaired    nutrition    of    the    aflfected    areas. 

The  chief  changes  in  the  skin,  according 
to  Schamberg,  are  an  increase  and  con- 
densation of  the  connective  tissue  in  the 
corium  and  the  subcutaneous  tissue,  an 
increase  in  the  elastic  tissue,  and  a  dimi- 
nution in  the  caliber  of  the  blood-vessels. 
Later  atrophy  of  the  subcutaneous  tissues 

Reines  reported  13  cases  which  seemed 
to  confirm  the  connection  between  sclero- 
derma   and    tuberculous    infection. 

Of  5  cases  of  diffuse  scleroderma  exam- 
ined by  Whitehouse,  3  gave  a  strongly 
positive  Wassermann  reaction,  1  a  faintly 
positive  and   1   a  negative  reaction. 

According  to  Ravogli,  1917,  the  under- 
lying factor  in  the  disease  is  a  disturbance 
of  equilibrium  of  the  internal  secretions  of 
the  adrenals,  thyroid,  etc.,  while  exposure 
is  often  the  determining  factor.  Criado, 
1918,  obtained  improvement  in  one  case  by 
adrenal  administration,  and  made  the  sug- 
gestion that  adrenin  be  also  used  locally. 

PROGNOSIS.— The  prognosis  is  ex- 
ceedingly unfavorable  as  regards  cure. 
The  disease  usually  persists  throughout 
life.  Improvement  occurs  in  quite  a  third 
of  the  cases.  In  adults  Lewin  and  Heller 
report  16  per  cent,  of  cures,  and  31  per 
cent,   in   children   under    15    years    of  age. 

TREATMENT.— The  treatment  con- 
sists in  nutritious  diet,  good  hygienic 
surroundings,  iron,  and  codliver  oil  in 
ascending  duses  (the  latter  up  to  10  table- 
spoonfuls  per  day);  sodium  salicylate;  ex- 
ternally, steam  baths,  mud  baths,  mer- 
cury (by  inunction),  galvanism,  and  mas- 
sage. The  most  recent  remedy  is  thyroid 
gland;  but,  according  to  Osier,  it  is  not 
of  much  value.  Brocq  recommends  elec- 
trolysis, at  first  at  comparatively  short 
intervals;  then,  when  amelioration  is 
manifest,  at  much  longer  intervals.  Elec- 
trolysis does  not  act  by  destructive  action, 
but  at  a  distance,  influencing  even  patches 
not  touched.  Philippsohn  obtained  excel- 
lent results  by  the  administration  of 
salol,  in  doses  of  about  7  to  15  grains 
(0.45  to  1   Gm.),  three  or  four  times  daily. 

S.  and  W. 

SCLEROSIS.     See  Index. 

SCOLIOSIS.  See  Spine,  Diseases 
AND  Injuries  of. 

INE.— Scoparius,  N.  F.  (spartium, 
broom,  broom-tops,  besom),  is  the 
dried  tops  of  Cytisus  scoparius  (fam., 
Leguminos?e),  a  densely  growing 
shrub  indigenous  to  Europe  and  ad- 
jacent Asia,  and  sparingly  naturalized 
in  sandy  soil  in  North  America.  Its 
long,  slender,  erect,  and  tough  twigs 
are  arranged  in  large,  close  fascicles 
which  lie  parallel  with  and  close  to 
one  another,  and  have  a  peculiar  odor 
wdien  bruised,  and  a  disagreeably  bit- 
ter taste.  The  quality  of  the  drug 
deteriorates  with  keeping,  the  pecu- 
liar odor  of  the  recently  dried  drug 
being  partially  or  completely  lost. 

Broom  contains  two  active  princi- 
ples, sparteine  and  scoparin. 

Sparteine  (Cir,H26N2)  is  a  trans- 
parent, oily  liquid,  colorless  when 
fresh,  but  turning  brown  on  exposure, 
having  an  odor  resembling  that  of 
aniline,  and  a  very  bitter  taste.  Spar- 
teine is  heavier  than  water.     It  is  but 



slightly  soluble  in  water,  but  readily 
dissolves  in  alcohol,  ether,  and  chloro- 
form, and  is  insoluble  in  benzene  and 
benzin.  Sparteine  contains  the  car- 
diac properties  of  scoparius. 

The  official  sulphate  of  sparteine  is 
prepared  by  dissolving-  10  parts  of  re- 
cently distilled  sparteine  in  40  parts 
of  diluted  (10  per  cent.)  sulphuric 
acid,  and  allowing  the  solution  to 
crystallize  in  a  warm  place.  It  should 
be  kept  in  well-stoppered,  amber-col- 
ored vials.  Sparteine  sulphate  occurs 
as  colorless,  rhomboidal  crystals,  or 
as  a  crystalline  powder,  odorless,  but 
having  a  slightly  salty  and  somewhat 
bitter  taste,  soluble  in  1.1  parts  of 
water,  2.4  parts  of  alcohol,  but  in- 
soluble in  ether  and  chloroform.  It 
is  hygroscopic,  and  its  aqueous  solu- 
tion has  an  acid  reaction. 

Scoparin  (C21H22O10)  is  a  gluco- 
side,  occurring  in  pale-yellow  crystals, 
without  odor  or  taste,  and  soluble  in 
alcohol,  alkalies,  and  in  hot  water.  It 
probably  represents  most  of  the  diu- 
retic properties  of  scoparius. 

— The  only  official  preparation  is : — 

Sparteincc  sulphas,  U.  S.  P.  (sparte- 
ine sulphate).  Dose,  y^  to  2  grams 
0.008  to  0.13  Gm.). 

Unofficial  but  serviceable  prepara- 
tions are : — 

Scoparius,  N.  F.  (broom-tops). 
Dose,  15  to  60  grains  ( 1  to  4  Gm.). 
usually  in  decoction. 

Decoctum  scoparii  (decoction  of 
broom,  made  by  adding  ^  ounce — 
16  Gm. — to  1  pint — 500  c.c. — of  water, 
and  boiling  down  to  /^  pint — 250 
c.c).  Dose,  1  ounce  (30  c.c.)  to  be 
taken  every  three  hours, 

Fluidextractum  scoparii,  N.  F. 
(fluidextract  of  broom).  Dose,  15  to 
30  minims  (1  to  2  c.c). 

Infusum  scoparii,  Br.  P.  (infusion 
of  broom,  made  by  adding  2  ounces — 
60  Gm. — of  dried  and  bruised  l)room- 
tops  to  20  ounces — 600  c.c. — of  boil- 
ing distilled  water;  infusing  in  a 
covered  vessel  for  fifteen  minutes  and 
straining).  Dose,  1  ounce  (30  c.c.) 
every  three  hours. 

Scoparin  (the  glucoside).  Dose,  8 
to  15  grains  (0.5  to  1  Gm.). 

Internally  broom,  in  large  doses,  ex- 
cites vomiting  and  purging,  and  in 
smaller  doses  increases  the  urinary 
output.  Sparteine  acts  upon  the 
heart  as  a  stimulant  or  tonic  like 
digitalin,  wiiile  scoparin  exerts  its 
action  upon  the  kidneys.  Sparteine 
has  a  decided  elTect  upon  the  nerves 
and  spinal  cord,  lowering  reflex  ac- 
tion, paralyzing  motor  nerves,  reduc- 
ing the  electrical  excitability  of  the 
vagus  and,  finally,  causing  death  by 
paralysis  of  respiration,  both  as  a  re- 
sult of  its  action  upon  the  center  and 
upon  the  respiratory  muscles. 

In  its  action  upon  the  circulation 
sparteine,  according  to  most  observ- 
ers, causes  a  transient  rise  in  ar- 
terial pressure,  followed  by  a  longer 
period  of  diminished  vascular  tension. 
Laborde,  however,  claims  that  spar- 
teine has  no  influence  on  the  blood- 
pressure.  Small  doses  slow  the  heart 
for  a  short  period  and  then  accelerate 
it,  the  volume  of  the  pulse  being  sim- 
ultaneously increased.  Large  doses 
cause  marked  depression  of  the  car- 
diac muscle,  and  of  the  vagus.  The 
heart  responds  to  its  action  in  about 
twenty  to  thirty  minutes,  and  the 
efifect  continues  for  from  six  to  eight 

No  cumulative  action  has  been  ob- 
served. When  taken  regularly  for 
several  weeks,  the  effects  continue  for 


several   days   after  discontinuing   the  solved  in  water  with  a  trace  of  am- 

remedy.  monia,  or  in  a  mixture  of  1   part  of 

In    its    action    on   the    muscles,    D.  glycerin  and  3  parts  of  water,  given 

Cerna    demonstrated    that    sparteine  hypodermically. 

causes    a    brief    period    of    increased  Sparteine  is  pre-eminently  a  heart 

muscular  irritability,  that  it  augments  tonic  and  heart  regulator,  rapid  in  its 

reflex    action    by    a    direct    influence  action,  certain  in  its  effects,  and  pro- 

upon  the  spinal  cord,  this  increase  be-  ducing    a    regulation    of    the    heart's 

ing  followed  by  a  subsequent  depres-  pulsations    in    more    ways    than    one. 

sion,  that  it  gives  rise  to  convulsions  If  the  pulse  rate  is  below  normal,  it 

of    a     spinal     origin     and     generally  will  cause  acceleration,  but  if  above 

tetanic,  that  it  causes  a  primary  in-  normal,  it  will  bring  it  down, 

crease   in   the   rate  and   force   of  the  Laborde  calls  it  the  "cardiac  met- 

heart's    action   by   a    direct    influence  ronome."      In     weak     and     irregular 

upon    the    heart,    the    increase    being  heart   Germain   See  advises  doses   of 

soon  followed  by  a  decrease,  due  to  from    ^    to    %    grain    (0.016    to   0.01 

direct  cardiac  action  and  stimulation  Gm.)    every    four    hours.      In    heart- 

of  the  cardioinhibitory  centers ;  it  aug-  failure,  the  result  of  mitral  disease,  it 

ments  the  blood-pressure  by  an  action  gives   the   best    results.      In   valvular 

upon  the  heart,  and  also  by  stimulat-  disease,  with  defective  compensation, 

ing  the  central  vasomotor  system ;  the  small  doses  are  apparently  more  efifi- 

arterial     pressure     subsequently     de-  cacious  than  large  ones.     Shoemaker 

clines,  owing  to  paralysis  of  the  vaso-  has    found    sparteine    of    service    in 

motor  system  and  a  direct  depressant  cases  of  enfeebled  cardiac  action  from 

action  upon  the  cardiac  musculature,  structural  lesions,  and  also  where  the 

It  is  claimed  that  sparteine  strongly  innervation  of  the  heart  was  markedly 

and  promptly  reduces  the  size  of  the  disturbed.      In    mitral    disease    it    is 

heart.  particularly  valuable,  even  in  the  ad- 

THERAPEUTIC  USES.— In  re-  vanced  stage,  when  dilatation  has  be- 
nal  insufficiency  with  deficient  urin-  gun.  In  cases  of  dyspnea,  palpitation, 
ary  secretion,  due  to  lowered*  arterial  and  cardiac  debility,  due  to  fatty  de- 
tension,  scoparius  yields  good  results ;  position  around  the  heart,  sparteine 
also  in  the  edema,  or  dropsy,  accom-  is  satisfactory.  In  dilatation  due  to 
panying  heart  lesions.  It  is  con-  valvular  disease  sparteine  may  be 
traindicated  in  the  acute  stage  of  given  hypodermically.  In  functional 
inflammation  of  the  lungs,  heart,  or  cardiac  disease,  the  result  of  exces- 
kidneys,  but  in  the  subacute  or  sive  bodily  or  mental  labor,  anxiety, 
chronic  stage  it  may  be  used  w^ith  and  in  "tobacco  heart,"  sparteine  will 
advantage.  In  hydrothorax  and  as-  yield  gratifying  results.  In  chronic 
cites  occasional  doses  of  compound  parenchymatous  nephritis  sparteine 
jalap  powder  may  be  combined  with  will  aid  in  the  elimination  of  urea 
it  to  advantage.  and  thus  prevent  uremia.  In  valvular 
Scoparin  has  been  used  as  a  diu-  cardiac  disease,  due  to  acute  articular 
retic  in  doses  of  from  8  to  15  grains  rheumatism,  cardiac  dilatation  with 
(0.5  to  1  Gm.)  by  the  mouth,  or  ^  failing  compensation,  chorea  asso- 
to   1    grain    (0.03  to  0.06   Gm.)    dis-  ciated   with    endocarditis,    exophthal- 


98                 SCOPOLAMINE    (HYOSCINE)  AND    SCOPOLA    (SAJOUS). 

mic  goiter,  etc.,  Cerna  has  obtained  scopola  (or  scopolia)  is  derived  from 

good    results    from    the    use   of   si)ar-  Scopoli,  an  Italian  who  was  professor 

teine.     In  morphine  addictions  spar-  of  botany  in  Pavia  about  the  middle 

teine  is  useful  in  supporting  the  heart  of  the  eighteenth  centur}^ 

and  system  during  the  withdrawal  of  Though  discovered,  the  one  in  hyo- 

the  drug.     In  postoperative  suppres-  scyamus    and    the    other    in    scopola, 

sion  of  urine,  postanesthetic  nausea,  hyoscine  and  scopolamine  are  identi- 

and    operative    shock,    Pettey    places  cal  chemically.     Most  of  the  drug  be- 

great    faith    in    sparteine,    but   insists  ing  obtained  from  scopola  rather  than 

that    the   dose   be    at    least    2    grains  hyoscyamus,  the  term  scopolamine  is 

(0.13  Gm.),  repeated  every  two  to  six  often  given  preference,  and  in  many 

hours,  when  the  effect  of  the  remedy  European    countries    it    is    the    only 

is  to  be  assured.     Hysterical  excite-  appellation  used. 

ment  is,  in  many  cases,  amenable  to  Officially,  that  is  to  say,  from  the 

sparteine  sulphate.  standpoint     of     the     United     States 

C.  Sumner  Witherstine,  Pharmacopoeia,  scopolamine  and  hyo- 

Philadelphia.  seine  are  identical  in  all  respects.     A 
slight  distinction  is,  however,   some- 

SCOPOLAMINE    (HYOSCINE)  times    made    between    the    two    sub- 

AND  SCOPOLA. — Scopolamine,  or  stances  with  respect  to  their  optical 

hyoscine  (C17H21NO4),  is  an  alkaloid  properties,    scopolamine   being   taken 

obtained  from  various  plants  of  the  to  refer  to  a  completely  levorotatory 

family    Solanacese,    including    Atropa  specimen    of    the    alkaloid,    i.e.,    one 

belladonna,  Datura  straniomum,  Hyo-  which  rotates  the  plane  of  polarized 

scyamus  nigcr,  and  Scopola  carniolica.  light  as  far  to  the   left  as   this   par- 

The    last-named    plant    is    an     herb  ticular  chemical  compound  is  capable 

growing    in    the    eastern    Alps,    Car-  of  doing  it,   and  is  composed  exclu- 

pathian   Alountains,  and  neighboring  sively     of      levorotatory      molecules, 

regions,   and   contains   about   0.6   per  while   hyoscine   is   taken   to   refer   to 

cent,  of  total  mydriatic  alkaloids,  in-  any    specimen    ranging   between    the 

eluding  0.06  per  cent,  of  scopolamine,  completely   levorotatory   and   the   in- 

Scopola  japonicas  is  another  species  of  active,  the  latter  being  a  mixture  in 

the  plant,  growing  in  Japan,  and  con-  equal  parts  of  levorotatory  and  dex- 

taining    the    same    principles    as    the  trorotatory  molecules.     The  optically 

European     scopola.      In     these     two  inactive  variety  of  hyoscine  is  termed 

plants,     scopolamine    is     present     in  atroscine.      Levoscopolamine,     imder 

larger  amount  than  in  the  other  mem-  the    influence    of    light,    is    gradually 

bers    of   the    solanaceous    group,    the  transformed    into    atroscine,    thereby 

next  being  hyoscyamus,  which,  in  its  suft'ering  some  reduction  in  its  pcriph- 

total  alkaloidal  content  of  0.08  to  0.15  eral   nervous    effects,    i.e.,    mydriasis, 

per  cent.,  contains  0.02  to  0.0375  per  vagal    paralysis,    arrest    of    secretion, 

cent,  of  scopolamine  (Kraemer).    The  etc.     For  ordinary  purposes,  however, 

histological   structure  of  the   scopola  scopolamine  and  hyoscine  are  gener- 

rhizome,  which  is  the  part  of  the  plant  ally  considered   equivalent.     Various 

used   in    medicine,    closely    resembles  preparations  that   have,   in   the   past, 

that  of  belladonna   root.     The  name  been  termed  hyoscine  have  consisted 


merely    of    a    more    or    less    impure  ally      administered      hypodermically, 

scopolamine.  though    oral    use   is    also    feasible,    the 

PREPARATIONS    AND    DOSE,  alkaloids   being  absorbed   with   almost 

— Scopolamincc  hydrobromidnm,  U.   S.  equal    certainty,    though    less    rapidly, 

P.  (scopolamine  or  hyoscine  hydrobro-  than  when  injected.     Solutions  of  the 

mide)   [Ci7HoiN40.HBr-)-3H20],  oc-  alkaloids  deteriorate  quickly  on  keep- 

curring   in   colorless    rhombic   crystals,  ing,    but    Straub    has    found    that    by 

sometimes  of  large  size,  with  an  acrid,  adding  to  them   5   to  20  per  cent,  of 

slightly  bitter  taste,  and  slightly  efflores-  mannite — a   harmless   substance   which 

cent.     It    is    soluble    in    1.5    parts    of  may  be  injected  into  the  tissues  with- 

water,  in    16  parts  of  alcohol,  and   in  out   fear   of  causing   local   irritation — 

750  parts  of  chloroform.     It  should  be  they    may    be    kept    for    an    indefinite 

kept  in  amber-colored  vials.    Dose,  ^^o  period  without  loss  of  activity, 

to  i/so  grain  (0.0002  to  0.001  Gm.).  PHYSIOLOGICAL     ACTION.— 

The  following  preparations  were  for-  Nervous   System. — Scopolamine    (hyo- 

merl}^  official: —  seine),  like  atropine,  produces  distinct 

Scopola,  U.    S.   P.   VIII    (scopola),  effects  on  both  central  and  peripheral 

the  dried  rhizome  of  Scopola  carnioHca,  nervous    structures.      Its    central     ef- 

required  to  yield  not  less  than  0.5  per  fects  differ  in  quality,  however,   from 

cent,  of  mydriatic  alkaloids.     Dose,  j/i  those  of  atropine,  consisting  chiefly  of 

grain  (0.045  Gm.).  a   pronounced    depression   of   the   psy- 

Fluidcxtractiim    scopolcc,    U.    S.    P.  chic  and   motor   centers   of   the   brain, 

VIII  (fluidextract  of  scopola),  contain-  the    result    being    a    hypnotic    effect, 

ing  0.5  Gm.  of  mydriatic  alkaloids  in  which   passes,   if    the    dose    be    large 

each  100  c.c.    Dose,  1  minim  (0.06  c.c).  enough,   into   narcosis.      The   electrical 

Extractum  scopolcc,  U.   S.   P.   VIII  excitability    of    the    brain    is    reduced, 

(extract   of    scopola),   made  by   evap-  The  human  subject  to  whom  scopola- 

orating  the   fluidextract,   and   required  mine     (hyoscine)     has    been    adminis- 

to    contain    2    per    cent,    of    alkaloids,  tered     becomes     quiet     and     sluggish. 

Dose,  %  grain  (0.01  Gm.).  because    of    early    depression    of    the 

Hyoscincc  hydrobromiduni,  U.  S.  P.  motor  centers,   and   soon   falls  asleep. 

VIII    (hyoscine  hydrobromide),  chem-  At  times  these  effects  appear,  after  a 

ically  identical  with  scopolamine  hydro-  short  period   of   latency,   with   marked 

bromide.     Same  dose.  suddenness,    and    their    intensity    may 

INCOMPATIBILITIES.  —  Hyo-  prove     alarming    to    nearby    persons, 

seine     and     scopolamine     are     incom-  Occasionally    sleep    is    preceded    by    a 

patible      with     alkalies,     tannic     acid,  short     period     of     excitement,     which 

potassium   permanganate,   iodides,   and  may    either    represent    an    attenuated 

salts    of    some    of    the    heavy    metals,  manifestation    in    scopolamine    of    the 

such     as     mercury     bichloride,     silver  delirifacient   action   of   atropine   or   be 

nitrate,      lead      acetate,      and      ferric  due  to  the  presence  of  the  convulsive, 

chloride.  highly    toxic    alkaloid    apoatropine    as 

MODES    OF    ADMINISTRA-  an  impurity.      (This  impurity  may  be 

TION. — Scopola,    when    used,    is    ad-  detected     by     adding     a     little     dilute 

ministered    by    mouth.      The    alkaloids  potassium    permanganate     solution     to 

scopolamine   and   hyoscine   are    gener-  the  solution  of  scopolamine,  the  violet 

100               SCOPOLAMINE    (HYOSCINE)  AND    SCOPOLA    (SAJOUS). 

color  changing-  to  a  yellow-brown  if  Respiration. — The  effect  on  the  re- 
apoatropine  is  present.)  In  excessive  spiratory  is  the  same  as  that  on  the 
amounts  scopolamine  induces  either  vasomotco"  center.  Respiration  is  de- 
coma  or — probably  only  if  impure — a  pressed  by  full  doses, 
condition  of  sleep  and  unconscious-  Eye. — Scopolamine,  instilled  in  the 
ness  interrupted  at  more  or  less  fre-  eye,  acts  like  atropine,  but  more 
quent  intervals  with  a  delirious  rapidly  and  in  an  amount  about  four 
outburst  or  low,  muttering  delirium,  times  less.  A  0.2  per  cent.  (1  grain 
Scopolamine  acts  upon  the  spinal  cord  to  the  ounce)  solution  will  dilate  the 
as  on  the  brain,  a  more  or  less  com-  pupil  in  ten  to  thirty  minutes,  and 
plete  depression  of  the  spinal  reflexes  shortly  thereafter  induce  paralysis  of 
being,  therefore,  characteristic,  espe-  accommodation.  These  effects  are 
cially  after  large  doses.  due   to    paralysis   of    the    oculomotor 

The  peripheral  nervous  effects  of  nerve  endings  in  the  constrictor  mus- 
scopolamine  are  essentially  those  of  cle  of  the  iris  and  the  ciliary  muscle, 
atropine,  consisting  of  depression  or  respectively.  The  drug  does  not  in- 
paralysis  of  the  terminals  of  the  vago-  crease  intraocular  tension.  Its  effects 
sacral  autonomic  system  and  of  the  on  the  eye  pass  off  more  rapidly  than 
secretory  nerves.  The  effects  of  atro-  those  of  atropine,  viz.,  in  three  to  five 
pine  on  the  pupils,  involuntary  mus-  days.  The  pupil  regains  its  normal 
cles  in  general,  and  secretions  are  diameter  in  about  seventy  hours,  and 
reproduced,  though  the  dosage  of  the  power  of  accommodation  is  re- 
scopolamine  for  simple  hypnotic  pur-  covered  in  four  days  (Oliver).  A 
poses  being,  as  a  rule,  less  than  the  slight  stinging  or  feeling  of  astrin- 
customary  full  dose  of  atropine,  these  gency  in  the  conjunctiva  may  be  ex- 
effects  are  not  as  often  noticed  as  perienced  after  its  instillation, 
w^ith  atropine.  Although  the  ability  Secretions.  —  Scopolamine  inhibits, 
of  scopolamine  to  paralyze  the  end-  like  atropine,  those  secretions  which 
ings  of  the  vagus  nerves  in  the  heart,  are  under  nervous  control,  paralyzing 
and  therefore  to  accelerate  heart  ac-  the  endings  of  the  secretory  nerves 
tion  is  not  questioned,  many  have  distributed  to  them.  Kamensky  wit- 
clinically  noticed  slowing  of  the  heart  nessed  arrest  of  the  salivary,  gastric, 
after  its  administration.  This  is  pancreatic,  and  sweat  secretions  by 
doubtless  either  an  indirect  eft'ect.  the  drug  in  laboratory  animals;  the 
the  result  of  motor  inactivity,  or  effect  on  the  pancreas  took  place 
due  to  admixture  of  some  cardiotoxic  much  later  than  that  on  the  other 
impurity.  secretions. 

Circulation.— Or d\n2ir\\y   no   cardiac  ABSORPTION  AND  ELIMINA- 

acceleration    is    induced    by    scopola-  TION. — Scopolamine    is    readily    ab- 

mine,  the  dose  used  being  too  small,  sorbed  from  mucous  membranes.     It 

The  alkaloid  differs  from  atropine,  in  is  more  rapidly  destroyed  in  the  sys- 

that  it  has  no  stimulating  effect  on  tern   or   excreted   than   atropine,   and 

the  vasomotor  center.    In  large  doses,  its     eff'ects     are     of    correspondingly 

it    depresses    this    center    from    the  shorter  duration. 

start,    a    corresponding    reduction    in  UNTOWARD     EFFECTS     AND 

the  blood-pressure  taking  place.  POISONING. — The  dose  of  scopola- 



mine  borne  without  unpleasant  re- 
sulting symptoms  seems  to  vary 
considerably  in  different  individuals. 
Occasionally  somnolence  and  dizzi- 
ness appear  in  ophthalmic  use  of  the 
drug".  In  persons  with  an  idiosyn- 
crasy therapeutic  doses  may.  in  addi- 
tion, produce  effects  similar  to  those 
of  beginning  atropine  intoxication, 
viz.,  dryness  of  the  mouth,  flushing 
of  the  skin,  mydriasis,  and  difficulty 
in  swallowing.  The  dose  ordinarily 
toxic  lies  between  ^Xoo  and  Yso  grain 
(0.0006  and  0.002  Gm.).  From  doses 
larger  than  are  required  for  thera- 
peutic effects  there  result,  in  addition 
to  the  symptoms  already  mentioned, 
ataxia,  indistinct  speech,  unconscious- 
ness, perhaps  followed  by  delirium 
and  hallucinations  and  an  accelerated 
feeble  pulse. 

Even  therapeutic  amounts  at  times 
produce  alarming  effects.  Thus,  cases 
of  collapse  from  ^,,0  grain  (0.0006 
Gm.)  have  been  reported,  with  pro- 
nounced muscular  weakness,  flushing 
of  the  face,  a  hard,  rapid  pulse,  noisy, 
rapid  breathing,  twitching  of  the 
hands,  and  cool  perspiration.  Col- 
lapse has  also  been  recorded  from 
ophthalmic  instillation  of  the  drug. 
M.  L.  Foster  has  reported  the  case  of 
a  young  man  in  whom  four  instilla- 
tions of  1  drop  of  a  0.2  per  cent,  solu- 
tion of  scopolamine  hydrobromide 
had  been  made  in  each  eye  at  ten- 
minute  intervals — total  amount  about 
Yqo  grain  (0.001  Gm.).  Fifteen  min- 
utes after  the  last  instillations  dizzi- 
ness appeared,  followed  by  dryness  of 
the  throat,  nausea  and  attempts  to 
vomit,  flushing  of  the  face,  motor 
weakness,  and  tachycardia  (over  160 
a  minute), attaining  their  maximum  in 
about  two  hours ;  the  patient  became 
cyanotic,  actively   delirious,  and  had 

what  appeared  to  be  toxic  convul- 
sions. Rapid  recovery  thereafter  took 
place  under  morphine  and  whisky. 
S.  W.  Morton  has  recorded  a  case  of 
poisoning  by  Y-,  grain  (0.0008  Gm.) 
of  hyoscine  hydrobromide,  with  in- 
ability to  swallow  and  complete  pa- 
ralysis of  the  soft  palate  and  upper  lip. 
In  an  ataxic  man  Gibbs  witnessed 
poisoning,  with  delirum  and  convul- 
sions, from  y^Q  grain  (0.0012  Gm.). 
R.  A.  Morton,  after  instillation  of  2 
drops  of  1  per  cent,  hyoscine  hydro- 
bromide into  the  eyes  of  an  adult, 
observed  muscular  relaxation  and  un- 
consciousness lasting  four  hours,  fol- 
lowed by  delirium  lasting  two  hours, 
and  then  sleep  lasting  one  and  one- 
half  hours.  F.  Krauss  observed  excite- 
ment lasting  over  seven  hours  in  a 
girl  of  15,  who  had  instilled  2  drops 
of  a  2-grain  to  the  ounce  solution  in 
each  eye  before  retiring. 

Fatal  results  from  scopolamine  in- 
toxication have  been  rare.  Bastedo 
has  met  with  fatal  collapse  from  %o 
grain  (0.0012  Gm.)  in  an  alcoholic 
man  with  pneumonia.  On  the  other 
hand,  he  witnessed  recovery  from  ^5 
grain  (0.0024  Gm.)  in  an  alcoholic 
woman  verging  on  delirium  tremens. 
In  each  of  these  cases  morphine  had 
preceded  the  hyoscine.  Recoveries 
from  ^  and  even  3^  grain  (0.03  Gm.) 
of  hyoscine  in  cases  subsequently  re- 
ceiving more  or  less  therapeutic  at- 
tention have  been  reported. 

Treatment  of  Poisoning. — If  the 
drug  has  been  taken  by  the  mouth, 
the  stomach  should  be  evacuated  with 
emetics  or  the  stomach-tube.  Tannic 
acid  or  Lugol's  solution  may  precede 
this,  if  they  are  immediately  at  hand 
and  the  case  is  seen  early.  As 
physiological  antidotes,  pilocarpine, 
J4  grain  (0.015  Gm.),  and  strychnine, 



Vso  to  1/20  grain  (0.002  to  0.003  Gm.), 
or  caffeine  sodiobenzoate,  5  grains 
(0.3  Gm.),  or  hot,  strong  coffee 
should  be  given.  Where  delirium  re- 
places the  unconsciousness  or  coma, 
sedatives  such  as  chloral  hydrate,  10 
grains  (0.6  Gm.)  ;  tincture  of  opium, 
15  minims  (1  c.c),  or  morphine,  % 
grain  (0.01  Gm.)  hypodermically,  may 
be  availed  of.  Electricity  and  other 
excitants  of  the  skin  surface  may  be 
used,  as  in  opium  poisoning,  to  com- 
bat narcosis.  In  cases  with  pro- 
nounced circulatory  depression,  digi- 
talis, epinephrin,  ether,  ammonia 
preparations,  etc.,  should  be  freely 
used.  Artificial  respiration,  external 
heat,  skin  frictions,  and  oxygen  in- 
halations are  other  measures  that 
may  prove  of  value. 

THERAPEUTICS  as  Sedative  to 
the  Central  Nervous  System. — In  in- 
somnia due  to  mental  excitement,  a 
persistent  wandering  of  the  mind 
from  one  subject  of  thought  to  an- 
other preventing  sleep,  and  in  the 
insomnia  of  neurasthenia,  scopola- 
mine (hyoscine)  in  small  doses,  such 
as  %oo  grain  (0.0002  Gm.),  is  of  value 
where  other  milder  hypnotics  fail  or 
have  to  be  discontinued  because  of  a 
tendency  to  habit  formation.  Though 
less  certain  in  its  effect  than  chloral 
hydrate,  scopolamine  has  advantages 
over  the  latter  in  being  of  small  bulk, 
non-irritating,  and  well  suited  for 
hypodermic  use.  According  to  Wind- 
scheid,  as  little  as  %5o  grain  (0.0001 
Gm.)  is  capable  of  causing  somno- 
lence. In  sleeplessness  due  to  pain, 
scopolamine  is  ineffectual  when  given 
alone,  but  if  combined  with  morphine 
in  small  amounts  proves  useful,  in- 
tensifying the  action  of  the  latter. 

In  the  insomnia  due  to  motor  ex- 
citation,   scopolamine    is    particularly 

effective.  This  applies  in  delirum 
tremens,  in  which,  e.g.,  Lambert 
recommends  a  combination  of  sco- 
polamine hydrobromide,  ^/|oo  grain 
(0.0006  Gm.),  with  apom^orphine  hy- 
drochloride, %o  grain  (0.003  Gm.), 
and  strychnine  sulphate,  fvQ  gram 
(0.002  Gm.),  administered  hypoderm- 
ically. Liepelt  found  it  more  active 
in  this  condition,  if  properly  applied, 
than  either  chloral  hydrate  or  mor- 
phine. In  the  delirium  of  infectious 
diseases,  including  pneumonia,  ty- 
phoid fever,  septicemir,  etc.,  scopola- 
mine is  of  value,  especially  where  a 
feeble,  dilated  heart  or  pronounced 
circulatory  impairment,  e.g.,  in  alco- 
holics, contraindicate  the  use  of 
chloral  hydrate.  For  this  purpose  it 
should  be  used  in  moderate  dosage — 
yi50  to  1/100  grain  (0.0004  to  0.0006 
Gm.).  If  the  first  dose  proves  totally 
ineffective,  or  the  delirium,  as  oc- 
casionally happens,  is  increased  in- 
stead of  diminished,  the  drug  should 
not  be  further  used.  Similar  consid- 
erations apply  in  the  insomnia  of 
infectious  diseases.  In  pronounced 
restlessness  in  neurasthenia,  scopo- 
lamine may  also  be  used  with 

In  acute  maniacal  states  the  use 
of  scopolamine  has,  to  a  considerable 
extent,  replaced  that  of  morphine. 
According  to  H.  S.  Noble,  in  the  re- 
curring forms  of  insanity,  maniacal 
attacks  can  often  be  averted  with  it. 
Such  patients,  at  the  first  intimation 
of  approaching  excitement,  are  given 
an  active  cathartic,  usually  mercurial, 
followed  by  1/100  to  1/75  grain  (0.0006 
to  0.0008  Gm.)  of  scopolamine  hydro- 
bromide  morning  and  evening,  rarely 
oftener.  Little  or  no  tolerance  to  the 
drug  is  established.  In  agitated 
melancholia   Doerner  found  scopola- 

SCOPOLAMINE    (HYOSCINE)  AND    SCOPOLA    (SAJOUS).               103 

mine  often  to  bring  about  quietude  scopolamine,  given  half  an  hour  be- 
when  all  other  means  had  failed.  The  fore  retiring,  of  great  value  in 
effect  comes  on  rapidly  and  lasts  from  controlling  the  spasmodic  cramps 
three  to  ten  hours,  according  to  the  sometimes  experienced  in  the  lower 
dose  given.  Insane  patients  are  often  extremities  on  retiring,  or  upon 
more  resistant  to  the  effects  of  sco-  stretching  in  the  morning.  The  same 
polamine  than  others,  doses  of  %4  author  successfully  employed  ^^s 
grain  (0.001  Gm.),  or  even  more,  be-  grain  (0.0008  Gm.)  at  night  to  arrest 
ing  sometimes  necessary ;  on  the  excessive  seminal  emissions.  Higier 
other  hand,  doses  as  small  as  ^-jO  found  the  drug  valuable  in  pruritus 
grain  (0.00025  Gm.)  are  sufficient  in  of  all  kinds,  except  diabetic.  It  has 
some  instances.  The  absence  of  un-  also  been  used  with  benefit  in 
pleasant  after-effects  is  a  marked  ad-  hiccough. 

vantage  of  this  drug.  In  the  tremor  of  paralysis  agitans 
Among  other  nervous  conditions  in  and  in  senile  or  alcoholic  tremor, 
which  scopolamine  may  be  availed  of  scopolamine  yields  prompt,  though 
are  status  epilepticus,  chorea,  hyster-  not  always  lasting,  effects.  It  may 
ical  convulsions,  and  the  convulsions  be  used  in  daily  doses  of  %4o  to  /42o 
of  cerebrospinal  meningitis.  Higier,  grain  (0.00025  to  0.0005  Gm.),  hypo- 
in  a  case  of  obstinate  chorea  occur-  dermically,  in  these  conditions,  and 
ring  in  pregnancy,  was  able  to  control  may  be  given  for  a  long  period  with- 
the  movements  by  giving  a  %o-grain  out  habituation  or  detrimental  effect. 
(0.001  Gm.)  dose  daily  for  a  week.  It  has  also  been  recommended  in 
In  nervous  asthma,  the  same  author  multiple  sclerosis. 

had   good   results   from   the   adminis-  In   the  night-sweats  of  pulmonary 

tration  of  %5o  to  %25  grain  (0.00025  tuberculosis  and  in  lead  colic  scopo- 

to  0.0005  Gm.)  subcutaneously  at  the  lamine     has    also     been     used,     with 

time    of    the    attack,    together    with  j^artial  success. 

smaller  doses  during  the  intervals  as  For   its   use  during  withdrawal   of 

prophylactic.     In  attacks  of  hystero-  morphine  from  habitues,  the  reader  is 

epilepsy  Nagy  usually  obtained  seda-  referred    to    the    article    on    Opium 

tion    in    five    to    twenty    minutes    by  Habit. 

means  of  an  injection  of  %4  grain  As  Mydriatic  and  Cycloplegic. — 
(0.001  Gm.)  of  the  drug.  In  tri-  For  refraction  purposes  scopolamine 
geminal  neuralgia  with  attacks  of  presents  certain  advantages  over  atro- 
muscular  contracture,  Pont  procured  pine,  and  is  even  preferred  to  the 
relief  of  pain  and  diminished  fre-  latter  for  routine  use  by  some  spe- 
quency  and  duration  of  the  attacks  cialists.  Two  instillations  of  a  drop 
of  contracture  by  giving  daily  injec-  each  of  a  1-grain  (0.06  Gm.)  to  the 
tions,  either  into  the  cheek  at  the  ounce  (30  c.c.)  solution  of  scopola- 
painful  spot  or  into  the  arm,  of  %-2o  mine  hydrobromide  at  an  interval  of 
grain  (0.0002  Gm.)  of  scopolamine  half  an  hour  are  sufficient  to  produce 
hydrobromide,  four  days'  treatment  complete  mydriasis  and  cycloplegia 
being  alternated  with  rest  periods  of  in  less  than  an  hour  after  the  first  in- 
equal  duration.  Noble  found  ''/120  to  stillation.  Even  a  1  in  1000  solution 
Yioo  grain   (0.0005  to  0.0006  Gm.)  of  is  usually  sufficient,  especially  if  the 



patient  is  required  to  instill  it  on  the 
evening-  before  and  the  morning'  of 
the  day  of  consultation.  The  myd- 
riasis and  likewise  the  paralysis  of 
accommodation  pass  off,  according  to 
the  amount  of  drug  used,  individual 
sensitiveness,  etc.,  in  from  two  to 
four  days,  thus  markedly  shortening 
the  period  of  disability  experienced  as 
compared  to  atropine.  Pressure  over 
the  lower  canaliculus  after  instillation 
is  recommended  to  minimize  the  pos- 
sibility of  constitutional  effects  by 
preventing  drainage  of  the  drug  into 
the  lachrymal  passages  and  nasal 
cavities,  whence  it  is  more  rapidly 

In  inflammatory  infections  of  the 
eye,  scopolamine  is  held  to  be  equally 
as  valuable,  or  more  valuable,  than 
atropine,  and  it  is  said  not  to  increase 
intraocular  tension.  In  rheumatic  or 
syphilitic  iritis,  it  may  be  combined 
with  or  substituted  for  atropine  in 
instillations,  and  may  also,  with  ad- 
vantage, be  given  hypodermically  at 
night  to  relieve  pain.  In  plastic  iritis 
scopolamine  acts  very  energetically, 
often  removing  synechise,  which  atro- 
pine had  failed  to  influence  (Raehl- 
mann).  In  uveitis  (serous  cyclitis), 
scopolamine  may  be  used  in  the  ab- 
sence of  increased  intraocular  tension 
(De  Schweinitz).  It  may  also  be 
substituted  for  atropine  in  sympa- 
thetic ophthalmitis. 

ANESTHESIA.— The  first  report  on 
anesthesia  produced  by  a  combina- 
tion of  morphine  with  scopolamine 
was  made  in  1900  by  Schneiderlin,  an 
alienist,  who,  having  used  the  drugs 
simultaneously  for  sedative  purposes 
in  restless,  insane  patients,  with  sat- 
isfactory results,  proceeded  to  employ 
them  to  induce  surgical  anesthesia  in 

demented  cases.  The  procedure  is 
based  chiefly  on  synergistic  action  of 
the  two  drug's  as  narcotics.  Although 
the  antagonism  between  them  in  cer- 
tain of  their  other  effects  might  be 
thought  of  marked  advantage,  per- 
mitting the  use  of  large  doses  with 
the  exclusive  view  of  causing  narcosis 
and  eliminating  apprehension  of  un- 
pleasant side  effects,  this  is  true  only 
to  a  slight  degree,  the  opposite  effects 
of  the  drugs  on  the  pupil  and  heart 
rate  having  but  little  value,  except  as 
indications  of  the  relative  degree  of 
action  of  the  drugs  in  the  individual 

The  experiences  of  Terrier,  E.  Ries, 
A.  C.  Wood,  W.  Wayne  Babcock, 
and  others,  have  shown  that  by  sub- 
cutaneous injection  of  scopolamine 
and  morphine  alone,  without  any  in- 
halation anesthetic,  a  satisfactory 
surgical  anesthesia  can,  in  many 
instances,  be  obtained.  This  is  es- 
pecially the  case  in  the  aged,  debili- 
tated, and  cachectic.  The  young-  and 
robust,  on  the  other  hand,  are  re- 
sistant and  show  a  tendency  to 
excitement  and  delirium  under  scopo- 
lamine, which  largely  unfits  them  for 
this  form  of  anesthesia.  Babcock, 
substituting  in  young  adults,  for  mor- 
phine and  scopolamine  (or  adding  to 
them)  apomorphine,  or  an  enema 
containing  Hoffman's  anodyne,  alco- 
hol, and  sometimes  paraldehyde,  has 
found  that  one  may  produce  general 
anesthesia  in  most  persons  over  18 
years  of  age  without  resort  to  in- 
halation of  ether  or  chloroform.  The 
procedure  proved  very  satisfactory — 
often  giving  results  superior  to  any 
other  form  of  anesthesia — in  opera- 
tions upon  the  head,  neck,  respiratory 
system,  and  spinal  column.  In  ab- 
dominal and  rectal  operations,  on  the 


other    hand,   and   to   some    extent    in  of  the  inhalation  anesthetic,  respira- 

operations  on  the  hands  and  feet,  it  tion  is  quiet  and  regular,  and  during 

was   found   inferior   owing  to  failure  the  operation  there  is  no  vomiting  or 

to     abolish     muscular     rigidity     and  obstruction  to  breathing  from  fluid  in 

reflexes.  the    air-passages.      While    the    pulse 

Morphine-Scopolamine  Preliminary  may  be   accelerated   by   the   scopola- 

to  Inhalation  Anesthesia. — In  spite  of  mine,  its  quality  remains  good.     The 

the  numerous  advantages  of  exclusive  patient  is  able,  where  the  part  oper- 

narcotic  anesthesia,  where  applicable,  ated  upon  permits,  to  take  water  or 

the  procedure  is,  in  general,  accorded  even    food    shortly    after    awakening 

only  a  small  field  of  application  be-  without    nausea    or    vomiting.      The 

cause  of  the  special  care  required  to  procedure    is    especially    valuable    in 

avoid  serious  respiratory  depression —  neurotic  subjects,  and  in  patients  with 

both  during  and  for  some  time  after  organic    disease    of    the    respiratory 

the  operation  by  the  narcotics  given —  tract.     A  much   larger  dosage  is  re- 

especially  the  morphine,  and  the  rela-  quired  in  alcoholic,  strong  men  than 

tively  high  mortality  which  has  fol-  in   aged   persons,   and   in   the    female 

lowed    its    application     in     unskilled  sex. 

hands.      Injection    of    morphine    and  According  to  Biirgi,  substitution  of 

scopolamine  in  smaller  amounts   be-  pantopon    (omnopon)    for    the    mor- 

fore    anesthesia    by    ether   or   chloro-  phine    in    the    morphine-scopolamine 

form,  on  the  other  hand,  is  considered  combination  is  of  advantage,  in  that 

less  dangerous  and  looked  upon  with  the    respiratory    center    is    less    influ- 

much  more  favor.    The  dosage  ranges  enced  and  the  likelihood  of  vomiting, 

from  %  grain  (0.01  Gm.)  of  morphine  A  %-grain  (0.04  Gm.)  dose  of  panto- 

and  K20  grain  (0.0005  Gm.)  of  scopo-  pon,  with  1/1.50  to  34oo  grain    (0.0004 

lamine  to  twice  these  amounts,  given  to  0.0006  Gm.)  of  scopolamine  is  held 

either   in    one   dose    one-half   to    two  to   be   without   danger   in    strong   in- 

hours  before  the  time  of  operation  or  dividuals   of    middle    age,    though    in 

in  divided  doses.     In  small-sized  pa-  delicate  or  old  persons  with  respira- 

tients,     doses     somewhat     less     than  tory    disturbances    the    dose    of    pan- 

those  mentioned  may  be  given,  e.g.,  topon    should    be    considerably    less. 

%    grain    (0.008    Gm.)    of    morphine  Reichel  and  Keim,  on  the  other  hand, 

and     ^.rjo     grain     (0.0004     Gm.)     of  specifically    mention    respiratory    de- 

scopolamine.  pression  as  a  possibility  in  the  use  of 

The  procedure  is  advantageous  in  pantopon.  Reichel  much  prefers  to 
many  ways,  allaying  the  patient's  ap-  substitute  for  the  latter  narcophine,  a 
prehension,  diminishing  after-pain  by  meconic  acid  compound  of  morphine 
lengthening  the  period  of  narcosis,  and  narcotine.  Keim  has  found  thirst 
and  distinctly  lessening  postanesthe-  a  troublesome  symptom  after  panto- 
tic  vomiting.  The  inhalation  an-  pon-scopolamine  anesthesia, 
esthetic  is  taken  quietly,  rapidly,  and  Morphine-Scopolamine  Preliminary 
without  struggling,  little  or  no  secre-  to  Local  and  Spinal  Analgesia. — 
tion  in  the  mouth  and  respiratory  In  local  and  spinal  types  of  analgesia 
tract  takes  place,  anesthesia  is  main-  the  patient  remains  alert  and  appre- 
tained  with  a  very  small  expenditure  hensive,    and    at    times    has    trouble, 

106               SCOPOLAMINE    (HYOSCINE)  AND    SCOPOLA    (SAJOUS). 

especially  under  local  analg"esia,  in  any  pain,  or  at  least,  if  pain  is  ex- 
keeping-  himself  under  control.  To  perienced,  recollection  of  it  after  the 
overcome  this  difficulty  and  facilitate  operation  is  completely  or  largely 
the  surgeon's  work,  as  well  as  in  local  1)lotted  out. 

analgesia,  which  is  frequently  incom-  Morphine-Scopolamine    in    Obstet- 

plete,    to    reduce    the    shock    to    the  rics. — The    combination   of   morphine 

nervous  system  from  tissue  injury  by  and  scopolamine  was  first  employed 

dulling  the  sensibility  of  the  sensory  in  obstetrics  in  1903  by  Steinbuchel, 

centers,    morphine    and    scopolamine  merely  to  reduce  the  pain  attending 

may  be  employed  to  great  advantage,  labor,  without  producing  any  degree 

W.    Wayne    Babcock    usually    orders  of  narcosis.    The  procedure  definitely 

administered,  one  hour  and  a  quarter  intended  not  only  to  reduce  suffering, 

before   the   induction   of  spinal   anes-  but    also    to    banish    the    memory    of 

thesia,   %   grain    (0.01    Gm.)    of  mor-  pain    after    the    completion    of    labor 

phine  sulphate  and  Vioo  grain  (0.0006  was,    however,    elaborated    by    C.    J. 

Gm.)    of   scopolamine   hydrobromide.  Gauss,  of  Kronig-'s  clinic  in  Freiburg, 

Where,   shortly   after,   the   patient   is  who   in    1907  reported    1000  cases   in 

not  in  a  condition  of  distinct  drowsi-  which  this  method  had  been  success- 

ness   (though  still  showing  some  re-  fully  applied.     In  the  following  year 

sponse  when  spoken  to),  an  additional  Kronig    reported    a    series    of     15O0 

dose  of  each  remedy  is  given  twenty  cases,    in   which   one    child    had   died 

minutes  after  the  first.     If,  as  is  the  during  delivery   and   three   others   in 

case  in  a  few  instances,  the  effect  is  the    first    three    days    after    delivery, 

still  insufficient,  a  third  dose  is  given.  Thereafter   it  was   not   until .  a   more 

sometimes  of  only  one  of  the  drugs,  recent  favorable  report  of  5000  cases 

stress  being  laid  rather  on  the  mor-  liad  been  made  by  Gauss  that  wide- 

phine  in  young  and  on  the  scopola-  spread    interest    in    the    method    was 

mine  in  older  subjects.     Before  major  reawakened. 

operations  under  local  anesthesia,  in  The  price  of  success  and  relative 
which  a  deeper  soporific  effect  is,  in  safety  in  the  use  of  this  procedure  is 
general,  of  advantage,  Babcock  sup-  held  by  many  to  be  a  rigid  adherence 
plements  the  morphine-scopolamine  to  the  somewhat  complex  and  pains- 
administration  with  a  narcotic  enema  requiring  original  method  of  Gauss, 
consisting  of  Hoffman's  anodyne  who,  in  the  process  of  obtaining  a 
(Spiritus  setheris  compositus,  U.S. P.),  simple  state  of  amnesia  with  partial 
^  to  1  fluidounce  (15  to  30  c  .c.)  ;  insensibility  to  pain, — the  so-called 
paraldehyde,  2  fluidrams  to  Yi  fluid-  twilight  sleep  (Dammerschlaf), — 
ounce  (8  to  15  c.c),  and  water,  5  carefully  adjusts  the  dosage  to  the 
fluidounces  (150  c.c).  At  the  con-  individual  case  by  means  of  a 
elusion  of  the  operation  2  quarts  (lit-  "memory  test"  carried  out  at  inter- 
ers)  of  normal  saline  solution  are  vals  during  the  course  of  labor.  In 
introduced  in  the  bowel  to  accelerate  primiparse,  the  first  sedative  injection 
elimination  of  the  narcotics.  By  these  is  given  when  good  uterine  contrac- 
means  the  patient  operated  under  tions  are  taking  place  every  four  or 
local  anesthesia  passes  through  the  five  minutes  and  persisting  at  least 
operation  without  being  conscious  of  one-half  minute.     This  injection  con- 


sists  of  0.01  Gm.  (%  grain)  of  mor-  Gm.  (Yi^o  grain).  This  is  followed 
phine  hydrochloride,  and  0.00045  Gm.  in  three-quarters  of  an  hour  by  0.0003 
(%40  grain)  of  scopolamine  hydro-  Gm.  (^/2oo  grain)  of  scopolamine 
bromide,  injected  separately  into  the  alone,  and  in  three-quarters  of  an 
buttock  or  thigh.  Three-quarters  of  hour  more  by  narcophine,  0.015  Gm. 
an  hour  later,  the  same  dose  of  sco-  (>^  grain),  and  scopolamine,  0.00015 
polamine  is  repeated  alone.  One-half  Gm.  (^/4oo  grain).  The  sedative  ac- 
hour  after,  a  memory  test  is  used,  the  tion  is  thereafter  maintained  by  re- 
patient  being  asked  how  many  injec-  peating  the  scopolamine  in  0.00015 
tions  she  has  had,  and  if  she  remem-  Gm.  (i/4oo  grain)  doses  every  two 
bers  some  strange  object,  such  as  a  hours.  Repetition  of  the  narcophine 
drinking-cup,  exhibited  to  her  at  the  is  seldom  required,  though  it  may  be 
time  of  the  first  injection.  The  mem-  given  at  six-hour  intervals  in  a  pro- 
ory  test  is  repeated  thereafter,  using  longed  labor. 

new  objects  each  time,  every  half-  Opinions  as  to  the  value  of  mor- 
hour,  and  if  memory  is  still  present  phine  or  narcophine-scopolamine  ad- 
one  and  a  half  hours  after  the  second  ministration  in  obstetrics  vary  from 
injection  a  third  injection  of  scopo-  enthusiastic  advocacy  of  the  measure 
lamine,  0.0003  Gm.  {Y200  grain)  only,  as  a  routine  procedure — barring  cer- 
is  given.  Subsequent  memory  tests  tain  definite  contraindications — to 
may  indicate  additional  injections  of  complete  condemnation.  B.  C.  Hirst 
scopolamine,  but  these  should  be  summarizes  the  disadvantages  of  the 
small,  and  given  only  at  long  inter-  method  as  "prolongation  of  labor, 
vals.  No  additional  morphine  is  ad-  tendency  to  atony  of  the  uterus  with 
ministered  after  the  first  dose.  To  hemorrhage,  and  an  increased  propor- 
permit  the  development  of  a  proper  tion  of  apneic  babies  that  could  not 
"twilight  sleep,"  absolute  quiet  and  be  revived."  With  minimum  doses 
plugging  of  the  patient's  ears  and  of  the  two  drugs  these  disadvantages 
covering  of  her  eyes  are  of  impor-  disappeared,  but  the  relief  afforded 
tance.  The  maternal  pulse,  pupil  re-  was  scarcely  noticeable.  He  found 
flexes,  and  temperature,  as  well  as  the  the  method  of  value,  however,  chiefly 
fetal  heart  rate,  are  to  be  taken  every  for  its  psychic  effect,  in  neurotic 
half-hour  so  quietly  that  the  patient's  primiparse  in  whom  a  long,  painful 
state  of  sopor  will  not  be  disturbed.  labor  is  considered  probable.  J.  C. 
In  order  to  increase  the  field  of  Applegate  noted  very  satisfactory  re- 
availability  of  the  method,  Siegel  has  suits  in  a  small  percentage  of  cases, 
elaborated  a  modified  Gauss  technique  but  accords  the  method  only  a  limited 
in  which  the  attempt  to  individualize  field  in  obstetrics.  Polak,  on  the 
the  dosage  is  abandoned,  a  standard  other  hand,  has  reported  a  series  of 
routine  dosage  being  prescribed,  and  155  cases  with  but  three  failures,  no 
no  memory  tests  used.  When  labor  fetal  mortality,  and  no  post-partum 
is  definitely  established,  the  first  in-  hemorrhage.  He  asserts  that  nar- 
jection  is  given,  consisting  of  narco-  cotization  of  the  child  (beyond 
phine  (morphine  and  narcotine  me-  oligopnea  for  a  few  minutes),  if  en- 
conate),  0.03  Gm.  ()^  grain),  and  countered,  is  not  the  fault  of  the 
scopolamine     hydrobromide,    0.00045  method,  but  of  the  dosage  and  man- 



ner  of  applying-  it,  and  that  the  actual 
fetal  mortality  is  lessened,  rather 
than  increased,  by  the  procedure.  In 
prirnipar?e  of  the  physically  unfit  type, 
commonly  becoming  exhausted  at  the 
end  of  the  first  stage  of  labor,  the 
method  brings  necessary  rest  be- 
tween contractions,  obviates  ex- 
haustion, and  greatly  reduces  the 
proportion  of  cases  requiring  high  or 
medium  forceps  application.  In  bor- 
der-line disproportion  cases,  if  opera- 
tive delivery  becomes  necessary,  this 
can  be  done  with  less  shock  and  less 
general  anesthesia.  In  cardiac  and 
tuberculous  cases,  Polak  uses  the 
method  to  reduce  the  strain  placed  on 
the  circulation  in  the  first  stage  of 
labor.  Contraindications  to  its  use 
are  emergency  conditions,  such  as 
precipitate  labor,  placenta  previa,  ac- 
cidental hemorrhage,  eclampsia,  pro- 
lapse of  the  cord,  primary  inertia,  and 
a  dead  fetus.  The  procedure  may  be 
applied,  however,  in  the  first  stage 
to  secure  dilatation  in  malpositions, 
scopolamine,  properly  used,  having 
been  shown  to  favor  dilatation  of 
the  cervix  and  reduce  uterine  spas- 
ticity. It  does  not  diminish  mam- 
mary secretion. 

L.  T.  DE  M.  Sajous, 


SCORBUTUS.— Scorbutus,  or  scur- 
vy, is  a  constitutional  disorder,  dependent 
upon  a  deficiency  of  vegetable  food,  and 
characterized  by  a  peculiar  form  of 
anemia,  great  mental  and  bodily  prostra- 
tion, spongy  gums,  a  tendency  to  the 
occurrence  of  mucocutaneous  and  sub- 
periosteal Hemorrhages,  and  a  brawny 
induration  of  the  muscles,  especially  those 
of  the  calves  and  the  flexor  muscles  of 
the  thighs. 

Scorbutus  has  almost  totally  disap- 
peared owing  to  the  wise  laws  enacted 
by  the  various  maritime  countries,  based 
on  the  discovery  that  deprivation  of  certain 

substances  present  in  fresh  fruit  and  vege- 
tables is  the  tmderlying  cause. 

SYMPTOMS.— The  early  symptoms  of 
scorbutus  are  a  rapidly  progressive  ane- 
mia, the  surface  becoming  dirty-looking, 
sallow,  pallid,  or  earthy  in  appearance;  a 
gradually  increasing  de))ility,  emaciation, 
and  indisposition  for  bodily  and  mental 
exertion;  arthritic  and  muscular  rheu- 
matoid pains  in  the  limbs  and  back;  men- 
tal apathy  or  depression;  dyspnea  upon 
slight  exertion;  the  tongue  may  continue 
clean,  but  it  becomes  large,  pale,  flabby, 
and  indented  by  the  teeth.  The  appetite 
usually  remains  good.  The  bowels,  as  a 
rule,  are  constipated. 

Other  manifestations  now  appear.  Pe- 
techial spots  arranged  about  the  hair-fol- 
licles are  observed,  first  on  the  lower 
extremities,  later  on  other  parts  of  the 
skin  surface.  These  spots  are  followed 
by  large  subcutaneous  extravasations  and 
puffy  swellings  in  various  parts  of  the 
body,  apparently  due  to  deep-seated  co- 
pious hemorrhages,  as,  later,  the  surface 
over  them  becomes  ecchymotic.  These 
swellings  chiefly  occupy  the  popliteal 
spaces,  the  anterior  aspects  of  the  elbows 
and  of  the  lower  part  of  the  legs,  the 
space  behind  the  angles  of  the  jaw,  and 
the  loose  connective  tissue  in  and  about 
the  eyelids,  giving  them  a  puffy,  bruised- 
like  appearance,  and  often  accompanied  by 
a  sanguineous  accumulation  in  the  sub- 
conjunctival tissue  covering  the  eyeball. 

The  gums  now  begin  to  swell,  especially 
at  the  edges,  become  spongy  and  lobu- 
lated,  rising  sometimes  above  the  teeth 
and  concealing  them.  They  are  deep-red 
or  livid  in  color,  bleed  easily,  ulcerate  or 
slough,  and  give  rise  to  an  exceedingly 
fetid  odor.  The  teeth  often  become  loose 
and,  in  exceptional  cases,  drop  out.  A 
tendency  to  ulceration  or  sloughing  be- 
comes more  or  less  general  in  all  parts 
of  the  cutaneous  surface,  more  especially 
at  the  locations  of  the  puffy  swellings,  be- 
ing easily  induced  by  a  slight  scratch, 
pressure,  or  blow. 

The  anemia  increases.  The  face  be- 
comes puffy  and  anasarca,  more  or  less 
marked,  appears  in  the  lower  extremities; 
dyspnea  develops;  the  heart-action  be- 
comes feeble  and  irregular,  and  the  pulse 
small,    soft,    and,    on    exertion,    much    ac- 



celerated.  The  slightest  exertion  excites 
attacks  of  sudden  syncope,  which  may  be 

Late  in  the  disease  the  appetite  is  apt 
to  fail;  the  bowels  become  loose,  the 
stools  being  usually  very  ofifensive,  and, 
not  infrequently,  containing  blood;  nerv- 
ous symptoms  are  now  manifest;  visual 
disorders,  including  hemeralopia  and  nyc- 
talopia, tinnitus  aurium,  vertigo,  insomnia, 
and  late  delirium  may  be  present;  menin- 
geal hemorrhage  may  occur.  The  intellect 
usually  remains  unaffected. 

During  the  progress  of  the  disease 
thoracic  complications  maj^  appear,  such 
as  pleurisy  with  effusion  (often  bloody), 
pulmonary  congestion  with  extravasation 
of  blood  into  the  lung-tissue,  bronchial 
congestion,  cough,  and  blood-stained  sputa, 
having,  not  infrequently,  a  gangrenous 

The  urinary  symptoms  vary.  Albumi- 
nuria is  not  rare.  The  specific  gravity  of 
the  urine  is  increased,  the  color  high,  the 
solids  diminished,  excepting  the  phos- 
phates, which  are  usually  larger  in  amount. 
Nephritis  may  occur. 

The  bones  in  chronic  cases  may  become 
congested,  or  even  necrotic,  and  the  epi- 
phyces  separate  from  the  shafts. 

The  duration  of  scurvy  may  be  several 
weeks  or  months.  Death  commonly  re- 
sults from  sudden  syncope  or  from  grad- 
ual asthenia,  hastened,  in  some  cases,  by 
the  occurrence  of  ulceration,  hemorrhage, 
thoracic  affections,  or  other  complications. 

DIAGNOSIS.— The  diagnosis  is  made 
from  the  history,  the  peculiar  facies,  the 
spongy  and  swollen  gums,  the  gingival 
and  deep-seated  cutaneous  hemorrhages, 
the  increasing  loss  of  strength  and  energy, 
the  mental  depression,  and  the  rapid  re- 
sponse to  correct  treatment. 

From  purpura  hemorrhagica  it  is  dis- 
tinguished by  its  chief  causative  factor — 
a  diet  lacking  in  fresh  vegetables  and 
fruits — by  the  spongy,  swollen  gums, 
loosened  teeth,  and  the  brawny  induration 
of  the  limbs.  In  purpura  hemorrhagica, 
the  ecchymotic  spots  are  not  arranged 
around  a  hair-follicle,  and  the  hemor- 
rhages from  the  mucous  membranes  are 
greater  in  amount. 

ETIOLOGY. — Tn  former  times  scorbu- 
tus was  prevalent  among  sailors  on  pro- 

longed voyages,  in  armies  in  active  service, 
and  among  people  suffering  from  famine. 
According  to  Osier,  the  disease  is  not  in- 
frequent among  the  Hungarian,  Italian, 
■  and  Bohemian  miners  in  Pennsylvania.  It 
is  rarely  epidemic.  It  is,  however,  en- 
demic, especially  in  parts  of  Russia  (Hoff- 
man) and  elsewhere,  sweeping  through 
prisons,  barracks,  almshouses,  and  institu- 
tions of  like  character. 

The  chief  predisposing  cause  is  a  long- 
continued  dietary,  lacking  in  certain  essential 
but  obscure  substances  found  in  fruits  and 
fresh  vegetables.  Unhygienic  surround- 
ings, excessive  muscular  exercise,  humid- 
ity, cold,  and  other  debilitating  influences 
are  recognized  as  etiological  factors.  Testi 
and  Beri  have  isolated  a  micro-organism 
which  the}'  believe  to  be  pathogenic. 

PATHOLOGY.— The  pathology  of  scor- 
butus corresponds  to  the  symptoms.  Mi- 
croscopic examination  of  the  blood  reveals 
the  presence  of  profound  anemia;  the 
blood  is  of  low  specific  gravity,  thin  and 
dark,  contains  an  excess  of  fibrin,  less 
hemoglobin,  and  fewer  red  blood-cells, 
but  there  is  no  leucocytosis.  The  skin 
may  be  the  seat  of  ecchymoses  (subcu- 
taneous hemorrhages),  but  the  most  char- 
acteristic hemorrhage  is  that  under  the 
periosteum  of  the  femora.  Extravasations 
of  blood,  in  various  stages  of  transforma- 
tion, may  also  be  found  in  the  lung-sub- 
stance, beneath  the  pleurae,  in  the  heart- 
muscle,  in  the  subpericardial  tissue,  in  the 
intestinal  parietes,  and  beneath  the  peri- 
toneal membrane.  Blood-stained  serum 
may  be  found  in  the  various  serous  cavi- 
ties. The  internal  organs  ma}-,  or  may 
not,  be  congested.  The  brain  is  usually 
intact.  The  heart,  liver,  and  kidneys  are, 
occasionally,  the  seat  of  parenchymatous 
or  fatty  degeneration. 

PROGNOSIS.— If  the  disease  has  not 
progressed  too  far  and  appropriate  treat- 
ment is  available,  the  prognosis  is  good; 
otherwise,  the  outlook  is  grave.  The  in- 
ternal symptoms,  especially  the  pulmo- 
nary, are  more  serious  than  the  external 
ones.  Pneumonia,  hemorrhagic  infarct  of 
the  lung,  pleurisy  with  bloody  effusion, 
acute  nephritis,  or  dysentery,  is  usually 
followed  by  death. 

TREATMENT.— Prophylaxis  demands 
an   adequate   supply   of  antiscorbutic  food 



for  long  seavoyagcs,  military  campaign- 
ers, and  explorers  in  the  frozen  zones. 
This  is  facilitated  by  the  present-day  abun- 
dance of  canned  fruits  and  vegetables, 
though  canning  may  reduce  their  value. 

In  the  treatment  of  the  disease  the  two 
indications  are  to  provide  a  diet  of  citrus 
fruits  and  of  vegetables  containing  the 
necessary  antiscorbutic  vitamincs  or  salts, 
and  to  combat  special  symptoms  and  com- 
plications. The  use  of  the  juice  of  two 
or  three  lemons  or  oranges  daily  will  be 
followed  by  marked  improvement. 

If  the  digestion  is  feeble  give  orange-  or 
lemon-  juice  combined  with  meat-juice  or,  milk  and  farinaceous  foods. 
When  the  condition  improves,  the  stronger 
animal  foods  and  fresh  antiscorbutic  vege- 
tables, such  as  potatoes,  water-cress,  raw 
cabbage,  onions,  carrots,  turnips,  tomatoes 
and  sauer  kraut  should  be  used  freely. 

Orange  peel  has  been  found  to  be  anti- 
scorbutic. According  to  A.  F.  Hess,  boiled 
orange  juice,  given  intravenously,  acts  like 
a  cliarm  in  scurvy. 

Ulcerations  in  the  mouth  may  be  healed 
by  using  a  mouth-wash  of  boric  acid  solu- 
tion. To  relieve  the  swollen,  spongy  gums 
a  2  per  cent,  solution  of  tannic  acid,  or  a 
mouth-wash  containing  boric  acid,  tincture 
of  myrrh,  and  compound  tincture  of  ben- 
zoin may  be   used. 

Twelve  cases  of  scurvy  in  the  Idiot 
Cottages  at  Kew,  Victoria,  all  in  crip- 
ples confined  to  bed  or  chair,  of  both 
sexes.  There  had  been  no  alteration 
in  the  dietary  of  the  patients  for 
years.  Other  patients  suffering  from 
the  same  crippled  conditions  and  with 
the  same  foods  were  unafifected.  The 
scurvy  cleared  up  in  t^^e  majority  of 
cases  shortly  after  the  patients  re- 
ceived a  special  dietary  of  raw  eggs, 
lime  water,  lemon  juice  and  raw  milk. 
Lind  (Med.  Jour,  of  Austral.,  Aug.  9, 
1919).  s.  and  W. 


See  Infantile  Scorbutus. 

SCROFULA.  See  various  forms 
of  Tuberculosis. 

berculosis OF  Skin. 

SEASICKNESS.—  D  E  F  I  N  I  - 
TION, — Seasickness  may  be  detined 
as  an  indisposition,  characterized  by 
giddiness,  nausea,  vomiting,  and  de- 
pression, produced  by  the  motion  of 
a  vessel  on  the  waves.  Closely  allied 
and  somewhat  similar  conditions  are 
elevator-  and  car-  sickness.  Regnault 
recognizes  two  forms  of  seasickness, 
the  somatic  (gastric)  and  the  psy- 
chical (nervous),  or  that  which  is  the 
work  of  the  imagination  or  results 
from  seeing  others  affected. 

SYNONYMS.— Seasickness  is  also 
known  as  naupathia ;  nausea  marina 
seu  maritima;  morbus  maritimus 
(L.)  ;  mal  de  mer,  naupathie  (F.). 

Vries  recognizes  four  stages :  depres- 
sion, exhaustion,  reaction,  and  con- 
valescence. In  mild  cases  the  patient 
is  but  slightly  ill,  sufifering  from 
malaise  and  giddiness,  followed  by 
tinnitus,  headache,  yawning,  and 
drowsiness,  with  some  gastric  dis- 
tress. In  more  severe  cases,  nausea, 
vomiting,  vertigo,  anorexia,  moderate 
prostration,  a  greenish  or  grayish 
pallor,  and  unsteadiness  of  gait  are 
present.  In  the  very  ill  great  pros- 
tration may  supervene.  Constipation 
or  diarrhea  may  be  present.  All  the 
secretions  are  diininished  (including 
the  menses)  except  the  saliva,  the 
flow  of  which  may  be  excessive. 
Diplopia,  pain  in  the  eyes,  scotoma, 
staggering  gait,  muscular  relaxation, 
backache,  neuralgic  pains,  alternating 
warm  flashes  and  chilliness,  weak  and 
rapid  pulse,  clamni}^  skin,  profuse 
diaphoresis,  insomnia,  fear,  and  a 
feeling  of  general  depression  are  com- 
monly noticed.  There  are  more  often 
mental  depression,  nervous  exhaus- 
tion, unpleasant  delusions  of  the 
senses  of  taste  and  smell,  and.  more 


rarely,    deficient    intellectual   control,  center,  which,  with  the  nuclei  of  the 

One  of  the  first  symptoms  in  certain-  eighth  nerve,  also  lies  in  the  fourth 

cases  is  an  abnormal  appetite,  which  ventricle.      There    follows    obstinate 

appears    as    soon    as    rough    water   is  vomiting,  often  associated  with  great 

encountered.  prostration.     The  endolymph  follows 

COMPLICATIONS  AND  SE-  the  motion  of  the  head  in  those 
QUEL.ffi. — Cerebral  hemorrhage  or  canals  whose  plane  corresponds  most 
the  rupture  of  a  previously  existing  nearly  to  the  direction  of  that  mo- 
gastric  ulcer  is  not  infrequent,  tion,  and  when  the  motion  is  sud- 
Brewer,  U.  S.  A.  Medical  Corps,  men-  denly  reversed  by  the  oscillation  of 
tions  a  case  in  which  the  vomiting  the  ship,  or  changed  in  direction  by 
was  so  severe  that  a  vessel  in  the  a  new  wave  striking  her  on  another 
stomach  was  ruptured  and  consider-  point,  the  endolymph  continues  in  its 
able  blood  lost ;  the  child  was  ill  for  original  direction  until  stopped  by 
several  days  after  landing.  He  re-  friction.  This  causes  undue  pressure 
ports  another  case  in  which  a  phy-  in  one  or  more  of  the  ampullae,  by 
sician  who,  in  addition  to  the  usual  which  wrong  impressions  are  con- 
symptoms,  sufifered  from  a  severe  veyed  to  the  sensorium,  and  in- 
diarrhea  whenever  the  sea  was  rough,  co-ordination    and    giddiness    result. 

Among  the  most  frequent  sequelae  Moreover,  the  otoliths  are  washed  up 
are  vertigo,  anorexia,  constipation,  against  the  nerve  filaments  at  the 
nervousness,  and  invalidism,  these  front  of  the  semicircular  canals  and 
symptoms  persisting  after  the  patient  produce  an  excessive  irritation,  which 
has  left  the  ship.  Bushby,  of  Liver-  is  expressed  in  vertigo  and  vomiting, 
pool,  reports  two  cases  of  severe,  James  L.  Minor,  of  Memphis,  calls 
prolonged  prostration  following  sea-  attention  to  the  freedom  of  deaf- 
sickness  and  associated  with  aceto-  mutes  from  seasickness  as  a  proof  of 
nuria.  Beard  mentions  the  case  of  a  its  aural  origin,  adding  that  nausea 
man,  sick  an  entire  year  at  sea,  who  and  dizziness  are  results  of  irritated, 
could  not  enter  any  place  where  the  but  not  destroyed  (as  in  deaf-mutes), 
air  was  foul  without  feeling  the  semicircular  contents, 
symptoms  of  seasickness.               .  The    theory    that    "anemia    of    the 

ETIOLOGY. — The  etiology  of  sea-  brain"  causes  seasickness  was  ad- 
sickness  is  far  from  being  absolutely  vanced  by  C.  Binz,  of  Bonn.  He 
settled.  Many  theories  have  been  claims  that  (1)  the  motion  of  the  ship 
advanced,  of  which  the  "endolymph  causes  constriction  of  the  arteries  of 
theory"  is  the  most  generally  ac-  the  brain  and  consequent  anemia  of 
cepted  one.  According  to  William  that  organ ;  (2)  this  acute,  local  ane- 
Edgar  Darnall  the  motion  of  the  mia  gives  rise,  as  at  other  times,  to 
waves  with  the  rhythmic  intervals  be-  rapidly  recurring  nausea  and  vomit- 
comes  transmitted  to  the  endolymph  ing;  (3)  the  retching  and  vomiting 
of  the  semicircular  canals.  This  con-  then  increases  the  volume  of  blood  in 
tinual  flowing  in  a  given  plane  over-  the  brain  and,  in  that  way,  relieves 
irritates  the  fine  hair-like  terminals  of  the  cerebral  anemia  and  removes  the 
the  vestibular  nerve  in  the  labyrinth,  sense  of  nausea ;  (4)  the  stomach 
and  reflexes  are  sent  to  the  vomiting  plays  a  passive  role,  being  influenced 


by  the  central  nervous  system  to  act  pressed   in   nausea   and   alteration  in 

whether  it  is  empty  or  full;  (5)  every-  the  respiratory  movements, 

thing  that  facilitates  the  flow  of  blood  Dubois  ascribes  a  causal  relation  to 

to  the  brain,  and  increases  the  same,  incomplete   ventilation   of  the   lungs, 

acts  as  a  prophylactic,  mitigates,  or  with     an     increase     in     residual     air, 

cures  the  seasickness.  and    imperfect    respiratory    changes. 

Germane  to  this  is  the  "theory  of  The  secondary  phenomena,  headache, 

Pflanz,"  that  the  constant  change  in  vomiting,    and     chills     are     referred, 

blood-pressure  and  in  the  fullness  of  etiologically,    to    the    spasmodic    and 

the  blood-vessels  produces  an  irrita-  forcible  contractions  of  the  diaphragm 

tion    in    the    brain    which,    when    it  with    a    consequent    displacement    of 

passes    the    stage    at    which    it    can  the  viscera. 

be    borne,    evokes    the    characteristic  Kenneth  F.  Lund,  of  Dublin,  after 

symptoms  of  this  condition.  reviewing  the  various  theories  as  to 

Metcalf  Sharpe  suggests  that  the  the  causation  of  seasickness  concludes 
condition  is  the  result  of  a  reflex  ac-  that  (1)  the  vomiting  is  not  due  to 
tion  of  the  stomach  due  to  a  central  the  unusual  impression  of  vision,  for 
stimulus ;  the  reflex  action  is  trans-  it  may  occur  on  land,  when  the  eyes 
mitted  to  the  solar  plexus  by  the  are  closed,  and  even  to  the  blind ;  (2) 
vagi ;  the  stimulus  probably  originates  it  is  not  due  to  smell,  as  any  unpleas- 
in  disorders  of  visual  accommodation,  ant  odor  may  cause  vomiting,  and 
for  by  paralyzing  the  accommoda-  may  occur  on  land,  and  to  any,  in- 
tion  of  one  eye,  by  means  of  a  myd-  eluding  deaf-mutes,  who  have  sensi- 
riatic,  he  found  that  the  symptoms  tive  nasal  organs ;  (3)  it  is  not  due  to 
were  greatly  lessened.  Hewitt,  of  momentary  displacement  of  viscera, 
London,  believes  that  interference  for  it  occurs  in  swinging  or  in  de- 
with  the  visual  center  predisposes  to  scending  upon  an  elevator.  The  sen- 
seasickness,  sation  is  present  whether  the  eyes  are 

According  to  W.  Janowski  seasick-  open  or  closed,  but  it  does  not  occur 

ness  is  an  expression  of  a  mild  form  in    deaf-mutes ;     (4)     there    is    some 

of  oft-repeated  cerebral  concussion.  mechanism    in    the    auditory    organ, 

The  surprise  of  the  mental  faculty  perhaps     the      semicircular      system, 

underlying   consciousness,    analogous  which  is  directly  affected  by  the  oscil- 

to   strong   emotional   disturbance,   as  lations  of  a  vessel  at  sea,  which  acts 

fright,  joy,  etc.,  is  given  by  Losee  as  as  a  stimulus  to  the  vomiting  center, 

the  causative  agent  in  this  disorder.  Finally,    the    nervous    element   and 

Dastre  and  Pampoukis  believe  that  power  of  the  imagination,  as  causa- 

there  is  a  combination  of  etiological  tive    factors,    should    not    be    disre- 

factors,  of  the   central   nervous    sys-  garded,  especially  in  those  of  a  highly 

tem,  the  pneumogastric,  the  splanch-  sensitive  and  nervous  temperament, 

nic,  and  the  phrenic  nerves,  and  that  Age    has    some    etiological    impor- 

the    displacement    of    the    abdominal  tance.      Children   and   the   very   aged 

viscera  and  their  slipping  motion  on  rarely   suffer   from   it,  although   chil- 

each  other  probably  cause  stimulation  dren   may,   purely   out   of   sympathy, 

of  the   Paccinian  bodies  of  the  mes-  Females  are  more  frequently  affected 

entery,    the    effect    of    which    is    ex-  than  males.     Only  from  Yz  to  5  per 



cent,   of  all   persons   escape.     Gihon  should  occur,  raise  the  head  or  sit  up 

estimates  that  5  per  cent,  are  immune,  awhile.     Keep  always  in  the  cool  air 

that  25  per  cent,  are  but  little  sick,  on   deck    with    pleasant    companions, 

that  60  per  cent,  are  a  great  deal  sick,  save  for  meals  and  bed,  moving  about 

and  that  10  per  cent,  are  distressingly  as  little  as  possible,  until  accustomed 

ill.  to  the  ship's  motion.    Avoid  oleagin- 

PROGNOSIS. — Seasickness  is  sel-  ous  smellsi  and  the  company  of  those 

dom,  in  itself,  a  menace  to  the  life  of  who   are  seasick,  as   suggestion   is  a 

a  patient.  powerful  excitant  to  seasickness. 

PROPHYLAXIS.— Choose    a    fa-  Avoid  cold  food.     Vichy  and  Ap- 

vorable  season    (spring  or   summer),  pollinaris   waters   may    be    freely    in- 

if  possible,  for  the  voyage.  Avoid 
sailing  on  the  long,  narrow  ocean- 
greyhounds     which     roll     with     each 

dulged  in  throughout  the  voyage. 
Small  and  frequent  (at  least  seven) 
meals    are    best.      M.    Charteris.    of 

swell   and   pound  the   ship   into   con-  Glasgow,  insists  that  the  diet  for  the 

stant    motion     with     their    powerful  first    two    days    should    be    dry    and 

engines,    but    select,    rather,    one    of  spare,  no  full  meals  being  taken,  and 

the   broad-beamed,   slow-going  boats  soups    and    pastries    always    avoided, 

which  are  now  so  well  fitted  for  the  If  there  is  any   tendency  to   nausea, 

comfort  of  the  passengers,  as  well  as  exertion  should  be  avoided,  as  much 

carrying    freight.      Select    stateroom  as  possible  ;  the  sufiferer  should  be  on 

and  deck   quarters   in   the   middle  of  his  back,  with  a  small  pillow  under 

the  ship,  near  its  transverse  axis,  the  the  head,  or  none. 

point  where  the  rolling  of  the  vessel  As  to  drugs  suggestions  are  numer- 

is    least    felt.      A    thorough    hepatic  ous.      No    drug    or    combination    of 

purge  should  be  taken  the  night  be-  drugs  is  infallible.     A.   D.   Rockwell, 

fore  embarking,  and  a  saline  on  the  of  New  York,   strongly  advises  bro- 

following  morning.     Go  on  board  the  mization — 100    grains    (6,6    Gm.)    in 

vessel  rested  in  body  and  with  a  tran-  divided    doses    daily    for    three    days 

quil  mind,  after  a  light  meal  on  shore,  before  sailing,  and  for  three  or  four 

with  which  a  little  wine  was  taken,  days  after  sailing.    Veronal  (sodium), 

but  scarcely  any  other  fluids.  a  favorite  with  many,   is  best  given 

The    clothing   should    be    of    light,  in  a  suppository  cont'aining  7^  grains 

pure,   woolen   material;   easy,   warm,  (0.5  Gm.),  although  5-grain  (0.3  Gm.) 

comfortable,  broad-soled  shoes  should  doses  may  be  given  in  tablet  form,  by 

be  worn.    A  good  flannel  roller  band-  mouth.     Chloretone,  another  favorite 

age,  12  feet  long  and  6  inches  wide,  remedy,    may    be    given    in    5-grain 

enveloping  firmly  the  whole  abdomen  (0.3  Gm.)   capsules,  tablets,  or  pow- 

will   frequently  afford   great  comfort  ders,   every   3   hours   for  3   doses,   so 

and  prevent  undue  movement  of  the  arranged  that  the  last  shall  be  taken 

viscera.  on    embarking.      For    short    voyages 

A  steamer-chair  and  rug  should  be  this   is   usually   effective ;   for   longer 

provided.     Recline  on  deck  in  a  shel-  ones    the   drug   should    be    continued 

tered  place,  amidship,  on  the  leeward  longer.    Validol,  higlily  recommended 

side,    comfortably   covered    and    with  by  many,  is  best  given  in  liquid  form 

eyes   closed.     If  cerebral   congestion  on  a  lump  of  sugar,  the  first  dose  be- 




\n^  30  drops,  the  second  25  drops,  and 
tlic  third  15  drops,  taken  an  hour 
apart,  the  first  dose  two  or  three 
lujurs  before  sailinj^.  It  may  also  be 
lakeii  in  doses  of  10  to  15  minims 
(0.6  to  1  (ini.),  repeated  half-hourly, 
if  rc(|uircd,  plain  (neat),  in  a  weak, 
alrolioHc  solution,  or  in  li(|uid  form. 
A  j)rophylactir  injection  of  '/,„)  ,i;rain 
(0.0006  dm.)  of  atropine  sulphate, 
combined  with  Hi,  ^rain  (0.(X)12  Gm.) 
of  strychnine  sulphate,  as  sut^^ested 
by  (lirard  and  olliers,  will  d(j  much 
to  inhibit  the  onset.  Avoid  the  use 
of  morphine,  cocaine,  and  parej^'oric, 
which  at  times  are  tlionL,ditlessly 

TREATMENT.— Whenever  the 
slis^lUest  sensation  of  illness  is  felt  He 
down  at  once  and  close  the  eyes. 
Usually  one  pillow  suffices,  and  if 
very  ill,  none  should  be  used.  Two 
teaspoon fuls  of  peptone  in  sherry 
wine,  poured  over  cracked  ice,  may 
be  ,i;iven  every  half-hour,  as  su£^- 
.q'ested  by  Sinclair  Tousey.  If  the 
patient  is  very  ill  and  cannot  eat  or 
retain  food,  11.  I'artsch  recommends 
an  egg-nog,  prei)ared  by  mixing  the 
yolks  of  two  raw  eggs  with  an  equal 
bulk  of  good  brandy  or  sherry  well- 
beaten  together,  and  given  in  tea- 
si)oonful  doses  at  ten-minute  inter- 
vals. Patients  with  severe  retching 
will  be  made  comfortable  by  lying 
down,  without  a  ])illow,  the  eyes 
closed;  a  pint  of  beer,  ale,  or  porter 
(brown  stout)  is  then  taken  in  six  or 
eight  portions  at  fivc-minute  inter- 
vals. Champagne  frappe  or  ginger 
ale  with  20  per  cent,  of  brandy  or 
whisky  is  highly  praised  by  many. 
When  champagne  is  used  it  is  advis- 
able to  allow  it  to  stand  until  effer- 
vescence ceases,  that  eructations  be 
avoided.     Beef-tea  or  meat  broths,  in 

tablespoonful  doses,  may  be  retained. 
Food  should  always  be  taken  at 
least  ten  minutes  before  arising  in  the 
morning,  and  when  the  patient  is  ill 
all  food  slunild  be  taken  without  rais- 
ing the  head.  The  best  time  to  take 
any  beverage  or  fo(jd  is  just  after  a 
l)aroxysm  of  retching.  Should  it  be 
taken  before  and  vomited,  then  take 
another  dose  immediately  afterward, 
and  that  will  stay  down  (11.  I'artsch). 
The  sicker  the  patient,  the  oftener  he 
must  eat,  and  the  less  at  a  time.  The 
bowels  should  be  kept  open  by  laxa- 
tives or  warm-water  enemas. 

The  drugs  most  in  favor  in  this 
condition  aie  veronal,  chloretone,  vali- 
dol  (the  administrati(jn  of  which  has 
been  already  described  under  ])rophy- 
laxis),  atropine,  atropine  and  strych- 
nine ccjinbined,  nitroglycerin  (s])iritus 
gly  eery  lis  nitratisj,  and  amyl  nitrite. 
The  bromides  have  largely  fallen  into 
disuse,  except  ior  rclieviiig  the  head- 
ache, because  they  tend  to  disorder 
the  digestion. 

Atro])ine  is  given,  to  increase  the 
cerebral  blood-su[)ply  and  to  relieve 
atony  of  the  vagus,  hypodermically, 
in  doses  of  /■'j^o  to  %(»  grain  (0.0005 
to  0.001  Gm.),  to  be  repeated  in  three 
or  fom-  hours,  if  necessary.  Atropine 
sulphate,  ^^o  grain  (0.0005  Gm.) 
may  be  advantageously  combined 
with  i/;„  grain  (0.001  Gm.)  of 
strychnine  sulphate. 

Nitroglycerin  and  amyl  nitrite  have 
been  used  in  full  doses. 

Rosenthal  has  shown  that  every 
reflex  action  can  be  i)revented  by 
•apnea.  This  principle  is  applied  for 
the  suppression  of  the  vomiting 
(which  is  due  to  a  reflex  stimulatitm 
of  the  center  in  the  fourth  ventricle) 
by  directing  the  patient  to  take  a 
series  of  deep  inspirations.    The  sue- 



cessful  experiments  of  Rosenthal  have 
been  repeated  by  R.  Heinz  and  M. 

Bier's  method  of  hyperemia  has 
been  successfully  used  by  Rosen  and 
by  Schlag"er  to  reheve  the  nausea  of 
seasickness.  The  hyperemia  was  in- 
duced by  fixing  an  elastic  band 
around  the  neck.  This  had  no  influ- 
ence on  the  tendency  to  vomit  when 
the  stomach  was  full,  but  when  the 
stomach  was  empty  the  tendency  to 
vomit  ceased.  The  band  was  always 
removed  at  night. 

Based  on  his  theory  (see  Etiology) 
M.  Dubois  advised  inhalations  of 
oxygen  under  pressure,  through  the 
mouth.  These  were  followed  by 
rapid  improvement.  The  number  of 
inhalations  was  not  very  large,  the 
amount  of  gas  inhaled  being  usually 
from  30  to  40  liters.  Dutremblay  and 
Perdriolot  attest  the  efficiency  of  this 

Wolf  applies  hot-water  compresses 
to  the  forehead,  as  hot  as  can  be 
borne,  and  rapidly  alternated.  They 
are  at  first  badly  tolerated,  but  after 
a  little  time  they  produce  a  thorough 
sense  of  relief.  Adrenalin  given  in- 
ternally has  also  been  praised. 

Ahhough  the  number  of  cases  in 
which  the  writer  used  benzyl  benzoate 
in  seasickness  is  small,  about  20  in 
all,  the  results  in  every  case  were  so 
satisfactory  that  he  feels  justified  in 
recommending  it.  In  his  cases  10 
drops  were  used.  As  the  sea  voyage 
was  short  in  all  cases,  he  was  not 
able  to  determine  how  long  the  effect 
of  the  drug  would  last.  Glenn  (Calif. 
State  Jour,  of  Med.,  Nov.,  1920). 
C'.  Sumner  Withekstine, 


SENEGA. — Senega  (senega,  snake- 
root)  is  the  dried  root  of  Polygala  senega 
(fam.,  Polygalacere),  a  perennial  herb  of 
eastern  and  central  North  America,  as  far 

south  as  North  Carolina.  The  constitu- 
ents of  senega  are  a  saponin-like  mixture 
made  up  of  polygallic  acid  (about  three- 
fourths  of  the  whole)  and  senegin,  a 
jmall  amount  of  methyl  salicylate,  resin, 
fat,  sugar,  etc.  It  contains  neither  tannin 
nor  starch. 

Senega,  U.  S.  P.  (the  dried  root).  Dose, 
10  to  20  grains   (0.60  to  1.20  Gm.). 

Fluidcxtractiiin  scnegice,  U.  S.  P.  (fluid- 
extract  of  senega).  Dose,  10  to  20  min- 
ims   (0.60   to    1.20  c.c). 

Syrupns  senega;,  U.  S.  P.  (syrup  of  sen- 
ega— 20  per  cent,  of  the  fluidextract). 
Dose,  1  to  2  drams   (4  to  8  c.c). 

Syrupus  scillce  compositiis,  U.  S.  P.  (com- 
pound syrup  of  squill,  hive  syrup,  croup 
syrup,  an  ofificial  substitute  for  Coxe's 
hive  syrup,  containing  8  per  cent,  fluid- 
extracts  senega  and  squill,  and  0.2  per 
cent,  tartar  emetic).  Dose,  10  to  30 
minims    (0.60   to   2.0   Gm.). 

Alistura  pcctoralis,  Stokes,  N.  F.  (Stokes's 
expectorant).  Dose,  1  dram  (4  c.c),  con- 
taining 2  grains  (0.12  Gm.)  each  of  sen- 
ega and  squill,  1  grain  (0.06  Gm.)  of  am- 
monium carbonate,  and  10  minims  (0.6 
c.c.  of  paregoric  in  syrup  of  Tolu.  This 
is  a  favorite  mixture,  though  not  official. 

is  an  expectorant,  alterative,  diaphoretic, 
and  diuretic  The  powdered  root  is  irri- 
tating to  the  air-passages  and  its  inhala- 
tion causes  sneezing.  When  the  root  is 
chewed  a  burning  sensation  follows. 
When  swallowed  in  large  doses  it  causes 
salivation  and  gastrointestinal  and  renal 
irritation.  It  is  an  irritant  to  the  skin. 
Used  as  an  expectorant,  it  does  not 
liquefy  the  secretions,  but  merely  facili- 
tates their  expulsion;  senega,  therefore,  is 
of  little  use  when  the  expectoration  is 
tough  and  scanty.  It  is  usually  combined 
with  other  expectorants  and  diuretics. 
Senega  is  excreted  by  the  bronchial  mu- 
cous membrane,  the  skin,  and  the  kidneys, 
exerting  a  stimulating  action  upon  these 

THERAPEUTIC  USES.  —  Senega  is 
cliicfly  used  in  subacute  and  chronic 
bronchitis,  in  the  chronic  bronchitis  of 
the  aged,  ijften  associated  with  emphy- 
sema, and  by  some  in  croup.  In  bronchial 
asthma     with     emphysema,     the     drug     is 




beneficial.  Whooping-cough  is  sometimes 
relieved  by  senega.  On  account  of  its 
diuretic  action  senega  has  given  relief  in 
the  dropsy  of  renal  disease  and  in  palpi- 
tation unasMiciated  with  cardiac  disease. 
In  amenorrhea  it  has  given  good  results. 
The  use  of  senega  in  heart  disease  is  not 
advised  on  account  of  the  depressing  ac- 
tion of  its  active  principle.  In  doses  of  2 
grains  (0.13  Gm.)  senega  has  been  given 
to  check  uterine  hemorrhage.  Senega  has 
been  given  in  chronic  rheumatism  for  its 
diaphoretic   and   diuretic   effects. 

SENNA.— Senna  is  the  leaflets  of 
Cassia  acutifolia  (Alexandria  senna)  and 
Cassia  angustifolia  (India  senna),  family 
Leguminoseae,  freed  from  stalks,  discol- 
olored  leaves  and  other  admixtures. 
The  principal  constituents,  according  to 
Tschirch,  are  one  or  more  glucosides, 
yielding  emodin,  an  extractive  substance 
(cathartic  acid)  and  a  large  amount  of 
gum  resin,  the  non-fermentable  sugar 
cathartomannite,  a  bitter  (sennapicrin), 
oxalic,  malic  and  tartaric  acids  combined 
with  calcium,  and  a  trace  of  volatile  oil. 
Senna  has  a  faint,  disagreeable  odor  and  a 
bitter,  nauseous   taste. 

Senna,  U.  S.  P.  (senna  leaves).  Dose,  1 
to  2^   drams    (4  to   10   Gm.). 

Fhiidextractum  senivcB,  U.  S.  P.  (fluidex- 
tract  of  senna).  Dose,  J^  to  1  dram  (2  to 
4  c.c). 

Infusum  sennce  compositum,  U.  S.  P. 
(black  draught,  containing  6  per  cent, 
senna,  12  per  cent,  manna  and  magnesium 
sulphate,  and  2  per  cent,  bruised  fennel 
seeds).  Dose,  2  to  4  ounces  (60  to 
120  c.c). 

Syrupus  senmu,  U.  S.  P.  (syrup  of  senna, 
containing  25  per  cent,  of  fluidextract). 
Dose,  1  to  2  drams  (4  to  8  c.c). 

Piilvis  glycyrrhiscE  compositus,  U.  S.  P. 
(compound  licorice  pow^der,  containing  18 
per  cent,  senna,  combined  with  washed 
sulphur,  licorice  powder,  fennel  oil,  and 
sugar).  Dose,  ^^  to  2  drams  (2  to  8  Gm.). 
Efficient  but  unofficial  preparations  are: 
Confectio  sennse,  N.  F.  (confection  of 
senna,  containing  the  pulps  of  cassia 
fistula,  prune,  tamarind,  and  fig,  with  10 
per  cent,  senna  flavored  with  coriander 
oil).     Dose,  1  dram  (4  Gm.). 

Syrupus  sennrc  aromaticus,  N.  F,  Dose, 
2  drams  (8  c.c),  representing  IS  grains 
(1  Gm.)  deodorized  senna,  6  grains  (0.4 
Gm.)  jalap,  and  2  grains  (0.13  Gm.)  rhu- 
barb,  with    aromatics. 

Syrupus  sennie  compositus,  N.  F.  Dose, 
2  drams  (8  c.c),  representing  16  grains 
(1.04  Gm.)  senna  and  4  grains  (0.26  Gm.) 
each    of   rhubarb    and    frangula. 

is  an  active,  but  not  acrid,  cathartic,  act- 
ing in  about  four  hours  and  producing 
copious,  yellow  stools,  with  some  griping 
which  may  be  avoided  by  combining  it 
with  aromatics.  It  is  a  feeble  hepatic 
stimulant,  rendering  the  bile  more  watery. 
The  menstrual  flow  may  be  excited  by  it, 
and  if  given  to  a  nursing  woman  her  milk 
thereby  becomes  a  purgative.  Injected 
into  the  veins  it  causes  vomiting  and 
purging,  and  in  overdose  a  drastic  cathar- 
tic, but  it  never  produces  poisonous  ef- 
fects. The  urine  acquires  a  red  color 
from  senna  medication,  if  it  is  acid,  but 
in  an  alkaline  urine  the  normal  yellow 
color  is   more  pronounced. 

THERAPEUTIC  USES.— This  drug  is 
a  safe,  efficient,  and,  when  combined  with 
other  drugs,  a  pleasant  cathartic  for  con- 
stipation. For  children  and  pregnant 
women  the  confection  and  the  compound 
licorice  powder  are  advised.  It  is  contra- 
indicated  in  threatened  abortion,  hemor- 
rhoids, and  where  the  intestines  are 


Wounds,  Septic. 


Nose  and  Nasopharynx,  Diseases  of. 

SERA.  See  Diseases  in  whicli 
these  are  used ;  also  Hematology. 

SERPENTARIA.  -  Serpentaria  is 
the  dried  rhizome  and  roots  of  Aristolochia 
serpentaria,  Virginia;  or  of  Aristolochia 
reticulata,  Texas  (fam.,  Aristolochiaceae). 
The  Virginian  species  may  be  found 
throughout  the  eastern  United  States, 
and  is  chiefly  collected  in  the  mountain- 
ous   districts    south    of    Pennsylvania    and 



the  Ohio  River.  Serpentaria,  an  aromatic 
bitter,  contains  a  volatile  oil  (0.5  to  1  per 
cent.),  a  bitter  principle,  tannin,  starch, 
sugar,  gum,  and  resin.  It  has  a  warm, 
pleasant  taste. 

Serpentaria,  U.  S.  P.  (the  crude  drug). 
Dose,   10  to  30  grains    (0.60  to  2   Gm.). 

Fluidextractum  serpentari?e,  N.  F.  (fluid- 
extract  of  serpentaria).  Dose,  10  to  30 
minims  (0.60  to  2  c.c.)-. 

Tinctura  serpentarire,  N.  F.  (tincture  of 
serpentaria,  20  per  cent.).  Dose,  J^  to  2 
drams  (2  to  8  c.c). 

pentaria has  a  stimulating  effect  upon 
gastric  secretion  and  is  added  to  other 
drugs  to  increase  their  absorption  and  ac- 
tivity. It  has  a  mild  diuretic  and  diapho- 
retic action.  In  larger  doses  it  pro- 
duces a  sense  of  fullness  in  the  head, 
nausea,  vomiting  and  intestinal  griping 
with  frequent  evacuations  of  semisolid 
stools.  Hemorrhoids  are  irritated  and 
menstruation  stimulated.  It  is  also  an 

THERAPEUTIC  USES.— Serpentaria 
is  a  good  general  tonic.  It  is  seldom  used 
alone.  In  atonic  dyspepsia  it  is  useful, 
combined  with  the  compound  tincture  of 
cinchona.  In  combination  with  the  aro- 
matic spirit  of  ammonia  it  is  beneficial 
in  pneumonia  of  a  low  type,  in  bronchial 
catarrh,  and  in  capillary  bronchitis.  It  is 
valued  as  a  restorative  in  typhus  and  ty- 
phoid fevers.  It  has  been  used  with  bene- 
fit in  chronic  rheumatism,  combined  with 
other  remedies.  Serpentaria  has  given 
good  results  in  amenorrhea  dependent 
upon  anemia  or  chlorosis. 

SHINGLES.     See  Herpes  Zoster. 

SHOCK.  — DEFINITION.  — A  gen- 
eral depression  of  the  vital  functions  due 
to  traumatism,  a  profound  emotion,  fear, 
etc.,  characterized  by  chemicophysical  dis- 
turbances in  the  nervous  system,  in  which 
deficient  adrenal  activity  and  vasomotor 
paresis  are  prominent  features. 

SYMPTOMS.— Shock  may  present  it- 
self in  forms  varying  in  intensity  froin 
slight  depression  to  profound  collapse  ap- 
proximating death.  In  severe  shock  the 
temperature  is  subnormal,  the  surface  is 
pale   or   livid   and   cool    or   cold,   the   skin 

being  clammy  and  perspiring  freely;  the 
eyes  are  staring  or  half-closed;  the  res- 
piration is  shallow  and  irregular,  and 
often  gasping;  the  pulse  weak,  rapid  and 
compressible  or  imperceptible.  A  notable 
fall  of  the  ])lood-pressure  is  usual.  These 
symptoms  in  severe  cases  are  accom- 
panied by  loss  of  consciousness;  in  the 
less  severe  cases,  consciousness  is  main- 
tained as  a  rule,  but  psychic  activity  ap- 
pears to  be  inhibited,  the  answers  to 
questions  being  monosyllabic  and  often 
unreliable;  even  in  mild  shock  mentality 
may  l)e  temporarily  dull  and  apathetic. 
Weakness  of  the  muscles  is  a  striking 
feature,  those  of  the  surface  being  flabby 
and  impotent;  the  sphincters  also  fail  to 
functionate  from  this  cause,  and  involun- 
tary evacuations  may  result.  The  pupils 
are  dilated,  as  a  rule,  and  react  but  slowly 
to  light.  Nausea  and  vomiting  may  oc- 
cur, but  this  is  rather  a  favorable  sign, 
since  it  is  often  the  precursor  of  a  reac- 
tion. Conversely,  hiccough  and  gastric 
regurgitation  are  unfavorable  signs.  Anu- 
ria is  frequently  noted. 

In  lethal  cases,  the  mental  torpor  grad- 
ually deepens,  syncope  comes  on,  and 
death  follows.  This  course  depicts  that 
observed  in  great  injury  involving  con- 
siderable loss  of  blood,  complicated  prob- 
ably with  abdominal  or  cerebral  lesions. 
Neurotic  individuals  and  drunkards  are 
also  exposed  to  this  rapidly  fatal   form. 

In  some  cases  the  picture  is  quite  dif- 
ferent. Maniacal  furor  seems  suddenly  to 
develop,  and  the  patient  throws  himself 
or  his  liml)s  in  every  direction,  rolls  his 
eyes,  strikes  right  and  left,  and  cries 
out  at  the  top  of  his  voice.  Usually  ex- 
haustion soon  comes  on  through  recur- 
rence, probalily,  of  hemorrhage  on  ac- 
count of  the  violent  exertion. 

In  cases  that  proceed  favorably,  the 
change  for  the  better  is  termed  the  "re- 
action." All  the  abnormal  symptoms  dis- 
appear gradually,  the  return  of  the  mus- 
cular tone  being  manifested  by  turning, 
shifting  position,  etc.,  while  the  cardiac 
symptoms  lessen  in  intensity  as  the  facial 
color  returns.  Some  cases  at  this  stage 
go  through  the  maniacal  type  of  shock 
through  unduly  rapid  resumption  of  cere- 
bral blood-pressure.  In  some  cases  it  is 
a  sign  of  septic   infection.     The  tempera- 



ture  in  a  favorable  case  remains  near  the 
normal,  though  it  may  exceed  this  to  a 
marked  degree  in  children  without  indi- 
cating that  a  complication  has  occurred. 
This  reaction  fever  sometimes  lasts  a 
couple  of  days,  then  gradually  disappears. 

As  regards  the  differential  diagnosis  of 
shock,  internal  Jiciiiorrhage  is  the  main 
source  of  confusion,  since  a  serious  trau- 
matism capable  of  causing  deep  shock  is 
capable  of  causing  also  some  organic  in- 
jury in  some  part,  local  or  remote,  of  the 
vascular  system.  This  question  assumes 
especial  import  after  an  operation  owing 
to  the  possibility  of  concealed  hemorrhage. 
In  the  latter  case,  however,  restlessness, 
tossing,  frequently  repeated  yawning,  in- 
tense thirst,  nausea,  impairment  of  vision 
due  to  retinal  ischemia,  and  repeated  at- 
tacks of  syncope  are  apt  to  occur.  Re- 
peated examinations  of  the  blood  will 
serve  to  place  the  differential  diagnosis 
on  a  surer  footing,  since  hemorrhage  pro- 
duces a  gradual  diminution  of  the  hemo- 
globin percentage,  while  uncomplicated 
shock  does  not  cause  such  a  change.  The 
cell  count,  both  as  to  erythrocytes  and 
leucocytes,  may,  however,  indicate  a 
marked  decrease,  but  this  is  probably  due 
to  recession  of  the  blood-mass  into  the 
splanchnic  area,  with  resulting  ischemia 
of  the  superficial  vessels.  It  is,  therefore, 
an  unreliable  sign.  An  abdominal  hemor- 
rhage may  give  the  physical  signs  of  an 
increasing  accumulation  of  fluid.  While 
the  onset  of  uncomplicated  shock  is  as 
a  rule  sudden,  the  exhaustion  due  to  hem- 
orrhage is  gradual,  and  finally  attended 
with  severe  asphyxic  phenomena,  which 
are  relatively  slight  in   shock. 

Delayed  shock  may  come  on  some 
hours  after  an  injury  or  a  violent  com- 
motion or  emotion,  such  as  is  witnessed 
in  street-car  or  railroad  accidents.  Anes- 
thetics, especially  chloroform  and  ether, 
inay  also  be  followed  by  shock,  not  only 
in  the  course  of  buti  after  their  use. 

Shell  Shock. — The  European  war  has 
shown  that  shells,  mines,  and  other 
agents  of  destruction  in  which  high  ex- 
plosives are  employed  may,  irrespective 
of  or  without  direct  physical  injury,  give 
rise  to  nervous  and  psychic  phenomena 
which  have  been  variously  attributed  to 
"shock,"    "physical    trauma,"    "concussion 

cerebri,"  etc.  In  the  milder  cases,  con- 
sciousness is  not  lost,  but  there  may  be, 
for  a  time,  severe  pain  in  the  head  and 
spine,  incoherent  speech,  trembling,  heavi- 
ness of  the  extremities  and  temporary 
anuria.  When  micturition  is  re-estab- 
lished, the  urine  may  be  found  to  contain 
albumin.     Uneventful  recovery  is  usual. 

In  the  more  severe  cases,  unconscious- 
ness, lasting  an  hour  or  more,  is  fol- 
lowed by  a  severe  "bursting"  headache 
with  some  deafness,  tinnitus  and  vertigo, 
sweating,  and  tremor,  or  rhythmic  spas- 
modic movements.  Incoherence  of  speech, 
mutism,  amnesia  and  various  disorders 
may  appear.  Catalepsy,  followed  by  con- 
vulsions, has  also  been  witnessed.  The 
reflexes  are  increasingly  active,  and  se- 
vere pain  with  hyperalgesia  in  various 
parts  of  the  body,  including  the  appen- 
dical  region,  may  be  complained  of.  The 
cases  usually  recover  in  from  one  to  three 
weeks.  Epilepsy  has  also  appeared  in  in- 
dividuals in  whom  a  history  of  this  dis- 
ease did  not  exist. 

Case  of  a  young  man  buried  in  a 
trench  by  the  explosion  of  a  shell, 
who  was  unconscious  when  rescued. 
Consciousness  was  regained  in  a  few 
hours,  but  he  was  totally  amnesic 
so  far  as  his  whole  life  was  con- 
cerned prior  to  and  including  the 
time  of  the  accident.  No  efforts  to 
recall  his  past  life  were  successful, 
but  the  practice  of  hypnotism  brought 
out  a  startling  result.  While  under 
hypnotic  influence  he  lost  his  new 
personality  completely  and  returned 
to  his  original  one  with  equal  com- 
pleteness. During  this  state  he  was 
able  to  recognize  his  father,  remem- 
bered all  of  his  past  life  to  the  mi- 
nutest detail,  and  could  even  give  an 
accurate  account  of  the  accident 
which  caused  his  mental  disturbance. 
Upon  recovery  from  hypnosis  each 
time  he  would  relapse  into  his  new 
personality  and  have  no  memory  of 
his  former  one.  During  the  studies 
made  of  him  in  each  of  his  two  per- 
sonalities, it  was  observed  that  his 
voice  and  his  handwriting  were  dif- 
ferent in  the  two  states.  In  one  re- 
spect his  original  personality  was 
retained  to  a  certain  extent,  namely, 



his  ability  to  play  a  certain  musical 
instrument.  Anthony  Feiling  (Lan- 
cet, July  10,  1915). 

Serious  disturbances  are  produced 
by  wounds  of  remote  localities,  and 
are  not  necessarily  psychogenic.  The 
shock  of  the  wound  may  cause  pro- 
longed unconsciousness  froin  which 
patient  emerges  speechless  or  voice- 
less. Physical  shock  must  be  in- 
voked to  explain  such  cases.  A  re- 
flex cause  could  be  excluded.  The 
disturbances  in  question  comprised 
aphasia,  phonasthenia,  dysarthria  in- 
cluding the  spastic  form,  and  kine- 
toses  of  all  kinds,  very  often  ac- 
companied with  exhaustive  states. 
Treatment  was,  for  the  most  part, 
imperfectly  successful  with  occa- 
sional good  results.  One  soldier 
upon  recovering  from  shock  after 
protracted  unconsciousness  showed 
total  aphasia.  As  this  passed  off 
dysarthria  and  dysphasia  were  left 
and  persisted  for  eight  months.  After 
this  bradylalia  was  the  only  symp- 
tom in  evidence.  Thirteen  months 
expired  before  he  could  resume  his 
duties  as  officer.  Gutzmann  (Berl. 
klin.  Woch.,  Feb.  14,  1916). 

This  fortunate  issue  is  not,  however, 
the  invariable  one.  In  some  individuals, 
after  weeks  or  months,  the  patients, 
though  apparently  recovered,  show  signs 
of  a  changed  disposition,  manifested  espe- 
cially in  abnormal  irrital)ility,  anxiety, 
apprehensiveness,  or  a  condition  of  high 
emotional  state.  These  may  be  attended 
with  hallucinations,  horrifying  dreams,  de- 
lusions, etc.  They  lose  interest  in  them- 
selves and  in  others,  become  unsocial  and 
morose.  The  repeated  revival  of  memo- 
ries of  horrible  events  in  the  trenches,  the 
death  of  comrades,  shell  bursts,  blowing 
up  of  their  trench,  etc.,  serve  to  sustain 
the  psychic  disturbance.  The  majority  of 
these  cases  recover,  however,  but  only 
under  well-directed  psychotherapy,  in 
which  sympathy  is  freely  dispensed. 
Wounds  tend  to  aggravate  the  trouble, 
and  even  to  produce  it. 

The  direct  effects  of  the  contusion 
from  the  air  are  of  extreme  variety, 
as    also    the    various    conditions    that 

may  be  observed  afterward.  Sudden 
death  from  the  shock  alone  is  not 
rare;  immediate  unconsciousness  is 
common.  It  may  last  for  hours  or 
weeks  and  be  followed  by  total  loss 
of  memory  for  the  period  since  the 
explosion.  The  effects  of  the  injury 
are,  in  reality,  nothing  but  traumatic 
hysteria.  When  the  shell  explodes 
near  a  sleeping  person,  it  does  not 
induce  the  nervous  and  mental  dis- 
turbances otherwise  observed.  This 
throws  light  on  the  importance  of 
the  fright  as  a  factor  in  the  shock. 
The  emotional-neurotic  factors  are 
supplemented  by  the  traits  for  which 
physical  exhaustion  is  responsible. 
An  exhausted  nervous  system  feels 
the  effect  of  the  explosion  more  than 
when  fresh  or  well  rested.  R.  Gaupp 
(Beitrage  z.  klin.  Chir.,  Apr.,   1915). 

From  the  156  cases  studied,  a  large 
majority  of  so-called  shell-shock 
cases  admitted  into  the  hospital  with 
functional  neurosis  in  some  form 
occurred  in  individuals  with  a  nerv- 
ous temperament,  or  with  an  ac- 
quired or  inherited  neuropathy.  In 
a  certain  numl)er  of  cases  the  cumu- 
lative effect  of  active  service  had 
produced  a  neurasthenic  or  hysteric 
condition  in  a  potentially  sound  in- 
dividual. Among  the  large  number 
of  officers  the  writer  has  seen  sent 
back  on  account  of  neurasthenia, 
none  have  exhibited  symptoms  of 
functional  paralysis  or  mutism.  Cases 
which  were  supposed  to  have  de- 
veloped epilepsy  as  a  result  of  shell 
shock  were,  usually,  individuals  who 
were  either  epileptics  or  potential 
epileptics  prior  to  the  shock.  F.  W. 
Mott  (Lancet,  Feb.  26,  1916). 


Although  the  term  "shock"  is  applied  to 
a  definite  clinical  syndrome  as  a  rule,  it 
is  often  made  to  cover,  pathogenetically, 
very  different  conditions:  hemorrhage, 
asphyxia,  reflex  inhibition,  etc.  Each  of 
these,  however,  has  its  own  pathology: 
cerebral  ischemia  in  hemorrhage;  deficient 
cellular  oxidation  in  asphyxia;  vasomotor 
paresis  in  reflex  inhibition,  etc.  True 
shock,    however,    has    a    patliology    of    its 



own,  changes  having  been  shown  to  occur 
in  the  nerve-cell  in  keeping  with  the  older 
teachings  based  on  the  histological 
methods  of  Golgi,  Marchi  and  Nissl  in 
"shocked"  animals.  The  alterations  found 
by  the  Golgi  method  consist  in  a  de- 
formity of  the  cell-body  advancing  to  the 
grade  of  actual  atrophy,  node-like  swell- 
ings on  the  dendrites,  and  fragmentation 
of  the  same.  By  the  Marchi  methods 
there  is  noted  degeneration  of  various 
spinal  tracts  and  columns.  As  observed 
by  the  methods  of  Nissl,  the  cytological 
alterations  are  various,  but  pronounced. 
Chromatolysis  is  present  in  a  large  number 
of  cells.  Changes  in  the  nucleus, — disloca- 
tion or  vcsiculation, — are  also  noticeable. 

As  a  result  of  the  central  disorder,  the 
vasomotor  system  becomes  more  or  less 
incompetent,  and  reduction  of  the  blood- 
pressure  follows;  the  peripheral  and  cere- 
bral vessels  are  depleted,  while  the  larger 
trunks  within  the  abdominal  cavity  are 
engorged.  This  may  explain  the  greater 
danger  of  a  fatal  issue  when  much  blood 
has  been  lost,  the  medullary  and  spinal 
changes  being  thus  accentuated. 

That  the  adrenals  become  inadequate 
from  the  same  morbid  action  on  their 
governing  center — the  sympathetic  center 
according  to  Sajous — seems  probable,  thus 
furnishing  another  causal  factor  for  the 
low  blood-pressure  noted.  According  to 
Crile  the  adrenal  adynamia  resulting  from 
shock  is  a  prominent  factor  of  this  con- 

The  labors  of  Elliott  and  Cannon, 
Seeley  and  Lyon  have  shown  that 
marked  epinephrin  exhaustion  occurs. 
From  the  fact  that  the  adrenal  ordi- 
narily contains  enormous  loads  to 
tide  the  individual  through  emergen- 
cies it  would  seem  that  the  storage 
and  discharge  factors  are  paramount 
over  the  secretory  roles.  Further 
than  this,  the  amounts  of  epinephrin 
needed  to  maintain  vasoconstriction 
that  exists  in  shock  are  evidence  of 
the  continued  output  of  that  secre- 
tion as  long  as  an  available  supply 
exists.  The  adrenal  cortex  in  shock 
seems  unaffected.  J.  F.  Corbett  (St. 
Paul  Med.  Jour.,  xvii,  655,  1915). 

Increased  quantities  of  epinephrin 
are  thrown  into  the  blood  during  con- 

ditions of  low  blood-pressure  and 
shock.  The  apparent  outpouring  of 
epinephrin  is  not  merely  a  hasty  dis- 
charge and  depletion  of  the  supra- 
renals;  since  the  quantity  of  epi- 
nephric  material  in  the  blood  actually 
increases  with  the  prolongation  of 
low  blood-pressure  and  shock,  there 
must  be  an  active  secretion  from  the 
glands.  The  suprarenals  seem  to 
function  as  a  line  of  secondary  de- 
fence against  a  falling  blood-pres- 
sure. The  presence  of  epinephrin  in 
increasing  amounts  as  shock  pro- 
gresses points  to  an  attempt  on  the 
part  of  the  circulation  to  redistribute 
the  blood,  bring  about  peripheral  con- 
striction of  the  arteries  wherever  pos- 
sible, and  thus  maintain  normal  pres- 
sure. Bedford  and  Jackson  (Proc. 
Soc.  of  Exper.  Biol,  and  Med.,  13,  85, 

The  writer  defines  shock  as  a  grad- 
ual progressive  fall  of  blood-pressure 
due  to  a  paresis  or  paralysis  of  the 
musculature  of  the  arterioles.  The 
only  way  in  which  he  has  been  able 
experimentally  to  produce  anything 
like  shock  is  removal  of  the  adrenals. 
Adrenalin  produces  a  good  effect  in 
shock  not  only  because  it  raises  the 
blood-pressure,  but  because  it  sup- 
plies a  something  which  is  essential 
and  in  these  cases  apparently  lacking. 
The  treatment  of  surgical  shock  con- 
sists in  continued  administration  of 
adrenalin  plus  efforts  to  remove  the 
causative  factor.  J.  E.  Sweet  (Amer. 
Jour.  Med.  Sci.,  May,  1918). 

Owing  to  these  organic  disturbances, 
the  contractile  power  of  the  vessels  is  lost, 
the  arteries  and  capillaries  becoming  de- 
pleted through  partial  transfer  of  the  blood 
into  the  deeper  venous  trunks,  thos^  of  the 
splanchnic  area  in  particular.  As  a  re- 
sult, various  organs,  especially  those  far- 
thest from  the  splanchnic  area,  the  brain, 
skin,  etc.,  and  those  of  the  thoracic  cavity 
are  rendered  ischemic.  Hence  the  low 
blood-pressure,  the  feeble  heart  action 
(due  in  part  to  deficient  adrenal  secretion 
and  the  resulting  deficient  contractility  of 
its  musculature),  the  deficient  respiratory 
activity  and  the  profound  adynamia  ob- 
served in  shock. 



Henderson  (1908)  has  attributed  shock 
to  a  loss  of  carbon  dioxide  through  the 
intermediary  of  the  blood  and  tissues  in 
the  course  of  operations  or  severe  solu- 
tions of  continuity.  Seelig,  Tierney  and 
Rodenbaugh  (1916)  have  sustained  this 
view  by  using  intravenous  injections  of 
sodium  bicarbonate  in  shock,  the  benefit 
obtained  being  attributed  to  the  power 
of  this  salt  to  break  up  in  various  tissue 
fluids  and  thus  liberate  carbon  dioxide. 
More  recently  fat  embolism,  acidosis, 
and  absorption  of  toxic  products  of  auto- 
lysis of  injured  tissues  have  l)een  empha- 
sized as  important  or  essential  factors  in 
the  production  of  shock. 

Fat  embolism  emphasized  as  a 
cause  of  shock.  An  undoubted  rela- 
tion exists  between  shock  and  broken 
bones,  particularly  when  large,  as  the 
femur.  In  8  experiments  on  cats,  in- 
jection of  fatty  substances  into  the 
jugular  vein  induced  a  clinical  pic- 
ture essentially  similar  to  traumatic 
shock  in  human  beings.  Fat,  ofien 
in  large  quantities,  is  known  to  enter 
the  blood  vessels  in  traumatic  shock. 
The  injurious  effects  are  due  to  fat 
embolism.  W.  T.  Porter  (Boston 
Med.  and  Surg.  Jour.,  Sept.  6,  1917). 

Where  there  is  low  blood-pressure 
in  shock,  hemorrhage,  or  gas  bacillus 
infection,  there  occurs  a  diminution 
in  the  available  supply  of  alkali  and 
hence  an  acidosis.  Operations  in 
shock  and  acidosis  cause  rapid  fall  of 
blood-pressure  and  sudden  decrease 
in  alkali  reserve.  Intravenous  injec- 
tion of  sodium  bicarbonate  produces 
quick  relief  of  acidosis  and  a  rise  in 
the  blood-pressure  in  shocked  men 
after  operation.  Cannon  (Jour.  Amer. 
Med.  Assoc,  Feb.  23,  1918). 

Report  of  investigations  showing 
the  extreme  toxicity  of  crushed  mus- 
cle tissue,  even  when  aseptic.  Ab- 
sorption of  this  muscle  autolysate  is 
undoubtedly  a  factor  in  traumatic 
shock.  Crushed  tissues  in  wounds 
should'  be  cleared  out  as  an  emergency 
measure  at  once,  without  waiting  for 
shock  to  subside.  Dclbct  (Bull,  dc 
I'Acad.  de  med..  July  2,  1918). 
Kinetic  Theory. — On  the  basis  of  some 
1200  experiments,  Crile,  of  Cleveland,  was 

led  to  conclude  that  the  key  to  shock  is  not 
in  the  vasomotor  system  alone,  but  in  the 
whole  motor  mechanism  of  the  body. 
Those  parts  of  the  body  having  the  great- 
est number  of  nociceptors — nerve-endings 
through  which  defensive  reactions  are 
provoked — and  which  defend  the  most 
vitally  important  structures,  are  those 
most  active  in  producing  shock  on  re- 
ceiving trauma.  Thus,  the  brain,  pro- 
tected as  it  is  by  the  cranium,  is  not  pro- 
vided with  such  nociceptors,  does  not  to 
any  marked  extent  awaken  shock  under 
operation  as  a  rule;  the  abdominal  struc- 
tures, on  the  other  hand,  which  are  richly 
provided  with  nociceptors,  readily  pro- 
duce shock  when  subjected  to  trauma. 
Now,  the  physical  basis  of  Crile's  theory 
is  that  when,  as  is  the  case  under  the 
influence  of  certain  anesthetics,  ether  for 
example,  the  reflex  motor  activity  which 
normally  occurs  by  stimulation  of  the 
sensitive  nerve-endings  fails  to  occur,  and 
there  is  no  response,  the  impulses  which 
reach  the  cortical  centers  from  the  periph- 
eral nerve-endings  excite  and  finally  ex- 
haust these  centers,  and  produce  in  them 
degenerative  lesions  similar  to  those  that 
histologists  long  ago  identified  as  the  char- 
acteristic cellular  lesions  of  the  condition 
known  as   shock. 

Crile  attributes  these  central  morbid 
changes  to  "work,"  i.e.,  excessive  oxida- 
tion or  febrile  process  carried  on  by 
those  organs  which  alone  are  capable  of 
transforming  latent  into  kinetic  energy, 
those  constituting  his  "kinetic  system," 
the  principal  organs  of  which  are  the 
brain,  the  thyroid,  the  adrenals,  the  liver, 
and  the  muscles.  According  to  Crile,  "the 
brain  is  the  great  central  battery  which 
drives  the  body;  the  thyroid  governs  the 
conditions  favoring  tissue  oxidation;  the 
suprarenals  govern  immediate  oxidation 
processes;  the  liver  fabricates  and  stores 
glycogen;  and  the  muscles  are  the  great 
converters  of  latent  energy  into  heat  and 
motion."  Yet  it  is  evident  that,  as 
Sajous  first  pointed  out  in  1903  (when  he 
showed  that  the  adrenal  secretion  circu- 
lated in  the  brain-cells),  it  is  to  the  pres- 
ence in  excess  of  the  adrenal  principle 
that  the  lesions  in  the  nerve-cells  are  due, 
for  Crile  calls  attention  to  the  "striking 
fact"  that  "adrenalin   alone  causes   hyper- 



chromatism,  followed  by  chromatolysis, 
and  in  overdosage  causes  the  destruction 
of   some  brain-cells." 

But  it  is  not  only  the  stress  of  trau- 
matism or  operative  procedures  on  the 
body  which  so  morbidly  affects  the  nerve- 
cells  of  the  cortex  among  others,  but  also 
fear,  anxiety,  the  anticipation  of  a  surg- 
ical operation,  emotional  excitement,  etc. 
All  these  factors  added  to  the  surgical 
traumatism  enhance  the  morbid  influence 
of  the  latter  on  the  nerve-cell. 

How  prevent  or,  at  least,  reduce  these 
effects,  which  in  the  aggregate  constitute 
the  condition  we  term  "shock"  and  which, 
moreover,  reduce  the  chances  of  operative 
recovery?  This  phase  of  the  question  is 
considered  below  in  the  subsection  on 
Prophylaxis,  under  the  title  of  "anoci- 
association,"  a  term  given  by  Crile  to  the 
measures  through  which  the  pathogenic 
stimuli  to  the  brain  may  be  controlled  and 
at  least  in  a  great  measure  prevented. 

PROPHYLAXIS.— The  prevention  of 
shock  during  operations  is  receiving 
greater  attention  as  time  progresses.  Be- 
fore resorting  to  any  serious  surgical  pro- 
cedure the  volume  of  urine  excreted  in 
the  24  hours  should  be  ascertained,  and 
an  examination  of  the  urine  itself  made, 
to  ascertain  that  the  kidneys  are  normal. 
This  is  important,  since  diseases  of 
these  organs  predispose  to  shock.  The 
excretion  of  urea  should  be  ascertained, 
for  if  it  falls  below  2  per  cent,  metabolism 
is  deficient;  such  a  condition  points  to 
asthenia  which  in  turn  predisposes  to 
neurasthenic  shock.  Violent  purging  pre- 
disposes to  a  similar  condition;  hence, 
while  freeing  the  intestinal  contents  is 
advisable  before  operation,  it  should  be 
done  only  by  means  of  aperients,  or  rectal 
flushing  with  saline  solution.  Some  sur- 
geons advise  the  use  of  morphine  hypo- 
dermically,  ^  grain  (0.008  Gni.)  given  20 
minutes  before  the  operation  to  quiet  the 
patient,  besides  the  influence  of  whatever 
anesthetic  is  used  in  that  respect;  yet 
others  are  opposed  to  opiates  in  any 
form.  The  truth  lies  between  the  two 
extremes;  large  doses  should  be  avoided. 

The  manner  in  which  the  anesthetic  is 
administered  has  much  to  do  with  the 
production  of  shock.  To  clap  a  towel 
saturated    with    ether   on    the   face    of  the 

already  frightened  patient  and,  as  far  as 
his  own  experience  is  concerned,  literally 
choke  him,  and  have  a  rough  orderly  hold 
his  arms  and  legs  to  prevent  struggling, 
besides  advertising  the  surgeon  and  his 
assistants  as  tyros,  favor  the  production 
of  precisely  the  histological  changes  in 
the  central  nervous  described  above  under 
Pathology  as  those  peculiar  to  shock. 
Everything  should  be  done  to  divest  the 
patient  of  fear  by  telling  him  that  he 
will  soon  be  asleep,  perhaps  feel  a  little 
"stuffy"  and  the  next  instant  (as  regards 
the  patient's  own  experience  is  concerned) 
awake  in  his  own  bed.  By  thus  sug- 
gesting that  he  will  be  subjected  to  no 
suffering  either  through  the  anesthetic 
or  the  operation  much  can  be  done  to 
pacify  him  and  otherwise  avoid  shock.  By 
using  the  drop  method,  Allis's  inhaler  or 
any  other  device  which  insures  the  pa- 
tient an  ample  proportion  of  air,  and 
avoiding  all  rough  handling,  but  little  if 
any   struggling   will   occur. 

Another  important  feature  is  to  main- 
tain the  surface  temperature  to  its  nor- 
mal level  as  nearly  as  possible  by  covering 
the  parts  other  than  those  exposed  for 
operative  purposes,  with  warm  blankets 
and  hot-water  bottles  outside  of  these 
(and  not  in  immediate  contact  with  the 
skin,  which  may  thus  be  burnt)  to  sus- 
tain the  heat.  The  loss  of  surface  heat 
when  the  body  is  allowed  to  become  cold 
causes  accumulation  of  the  blood  in  the 
splanchnic  area,  an  important  pathologi- 
cal feature  of  shock.  For  the  same 
reason  as  little*  blood  as  possible  should 
be  lost  and  the  operation  performed  as 
rapidly  as  safety  and  thoroughness  will 

seen  under  the  heading  Kinetic  Theory  un- 
der Pathology,  that  Crile  means  by  this 
term  a  physical  exhaustion  of  the  cerebral 
nerve-cells,  brought  about  by  abnormally 
active  stimuli,  trauma,  pain,  fear,  emotion, 
etc.  His  experiments  showed,  moreover, 
that  the  central  lesions  produced  in  the 
course  of  surgical  operation  could  be 
prevented  by  blocking,  as  it  were,  the 
connection  between  the  traumatized  part 
and  the  brain-cells  by  a  technique  to 
which  he  gave  the  name  "anoci-associa- 
tion."     Morphine  and  scopolamine  having 



been  found  to  conserve  the  output  of 
energy,  thus  avoiding  the  transmission  of 
excessive  stimuli  to  the  brain-cells,  they 
form  the  foundation,  as  it  were,  of  his 
method.  His  technique,  as  exemplified  by 
its  application  in  abdominal  work,  is  as 
follows: — 

In  patients  other  than  infants,  the  aged, 
and  the  asthenic,  Crile  administers,  on  an 
average,  %  gr.  (0.01  Gm.)  morphine  and 
Kno  gr.  (0.0004  Gm.)  scopolamine  one  hour 
before  operation.  If  local  anesthesia  alone 
is  employed,  novocaine  in  1:400  solution 
is  used  by  local  infiltration.  ,  If  inhalation 
anesthesia  is  employed,  nitrous  oxide  is 
administered,  either  alone  or  with  ether 
added  as  required.  As  soon  as  the  pa- 
tient is  unconscious,  first  the  skin  and 
then  the  subcutaneous  tissues  are  in- 
liltrated  with  1:400  novocaine.  The  novo- 
caine is  spread  by  immediate  local  pres- 
sure with  the  hand.  Incision  through  this 
anesthetized  zone  exposes  the  fascia, 
which  is  novocainized,  subjected  to  pres- 
sure, and  then  divided.  In  succession  also 
the  remaining  muscles  or  posterior  sheath 
and  the  peritoneum  are  infiltrated  with 
novocaine,  subjected  to  pressure,  and  di- 
vided within  the  blocked  zone.  If  the 
blocking  has  been  complete,  then  within 
the  opened  abdomen  there  will  be  no 
increased  intra-abdominal  pressure,  no 
tendency  to  expulsion  of  the  intestines, 
and   no  inuscular  rigidity. 

The  peritoneum  is  next  everted  and  in- 
filtrated with  a  Zl-i  per  cent,  solution  of 
quinine  and  urea  hydrochloride,  so  that 
the  line  of  proposed  suture  is  completely 
surrounded.  As  before,  momentary  pres- 
sure serves  to  spread  the  anesthetic.  This 
infiltration  of  quinine  and  urea  hydro- 
chloride serves  as  a  block  which  may  last 
for  several  days.  It  prevents  or  minimizes 
postoperative  shock.  It  causes  a  certain 
amount  of  edema  of  tissue  which  lasts 
for  some  time  after  the  wound  is  healed. 

With  this  technique  the  relaxed  abdom- 
inal wall  permits  the  easy  and  gentle  ex- 
ploration of  the  entire  abdominal  cavity. 
If  there  is  no  cancer  in  the  field  of  oper- 
ation and  if  no  acute  infection  is  present, 
then  the  following  regions  may  be  blocked 
as  completely  and  in  the  same  manner  as 
the  abdominal  wall — namely,  the  meso- 
appendix,  the  base  of  the  gall-bladder,  the 

uterus,  the  broad  and  the  round  ligaments, 
the  mesentery,  and  any  part  of  the  pari- 
etal peritoneum.  Since  operations  on  the 
stomach  and  intestines  cause  no  pain  if 
they  are  made  without  pulling  on  their 
attachments,  no  novocaine  block  is  re- 
quired   in    such    operations. 

In  operations  carried  out  in  this  manner 
the    closure   of   the    upper   abdomen    is    as 
easy   as   the    closure    of    the    lower;    all   is 
done  with  ease  in  perfect  relaxation.    No 
matter  how  extensive   the  operation,   how 
weak  the  patient,  or  what  part  is  involved, 
if   the   technique   is   perfectly   carried   out, 
the  pulse  rate  at  the  end  of  the  operation 
is    the    same    as    at    the    beginning.      The 
postoperative     rise     of     temperature,     the 
acceleration    of    the    pulse,    the    pain,    the 
nausea,   and   the   distention   are   minimized 
or   wholly   prevented   according   to    Crile. 
The  cause  of  the  high  mortality  of 
operations  on  the  gall-bladder  is  ex- 
haustion   and    shock,    the    exhaustion 
of  the  vital   organs   of  the  body.     In 
excision    of    the    liver    and    adrenals 
within    a    few    hours    the    blood    be- 
comes   acid.      In    every    case    of    ex- 
haustion    the     same     changes     were 
found    in    the    brain,    liver,    and    the 
adrenals.      Postoperative    pain    finally 
overcomes  the  margin  of  safety  and 
the    patient    dies.      Neutralization    of 
the   acids   is   one  of  the  most  impor- 
tant   functions    of    the    liver.      Every 
response  to  stimuli  produces  an  acid 
condition.     The    margin    of    safety    is 
reduced     in     exhausted     patients     by 
this    acidosis.      An    increased    acidity 
always    accompanies   inhalation   anes- 
thesia.      Ether,     however,     adds     an- 
other   strain.      The    liver    finally    be- 
comes   no    longer    able    to    neutralize 
the   acidity.      The   only   cure   for   the 
acidosis  is  prevention,  which  may  be 
largely    accomplished    by    increasing 
the    store   of    energy    and    preventing 
the  waste  of  it.     Glucose   and  bicar- 
bonate  of   soda   and    sleeping  in   the 
open    air    will    increase    the    store    of 
energy.     Morphine  does   not  increase 
the   aciditj^   of   the   blood,    but    if   the 
latter   is   once   produced    by    emotion, 
starvation,    or   whatever   cause,   large 
doses  of  morphine   will  then  rob  the 
body  of   its   power   to   neutralize   the 



acidosis.  But  if  given  before  the 
acidosis  occurs,  the  morpliinc  will 
not  have  anj'  effect.  Psychic  rest  is 
obtained  by  twilight  anesthesia.  If 
the  margin  of  safety  is  very  narrow 
the  operation  should  be  done  in  two 
stages.  Avoidance  of  injury  to  the 
splanchnic  nerves  is  insisted  upon. 
Crile  (X.  Y.  Med.  Jour.,  July  4,  1914). 

As  a  preliminary  narcotic  a  com- 
bination of  omnopon  and  scopolamine 
is  recommended.  It  is  also  valuable 
to  give  a  dose  of  veronal  on  the 
evening  preceding  the  operation.  The 
writer's  method  of  producing  local 
anesthesia  for  abdominal  operations 
is  essentially  the  anesthetization  of 
the  several  nerve-trunks  laterally 
upon  the  abdomen  through  5  or  6 
punctures.  The  solution  consists  of 
0.4  Gm.  (6^2  grains)  of  potassium 
sulphate  and  12  drops  of  synthetic 
adrenalin  to  each  100  c.c.  of  ''/^ 
per  cent,  solution  of  novocaine.  All 
the  tissues,  from  the  skin  to  the 
peritoneum,  should  be  infiltrated  at 
the  site  of  each  puncture.  In  addi- 
tion to  this  the  line  of  incision  is 
infiltrated  in  a  similar  manner,  and, 
if  necessary,  additional  infiltration  of 
the  mesenteric  attachments,  etc.,  may 
be  made.  With  his  technique  the 
writer  had  only  2  cases  of  post- 
operative shock  in  well  over  2000 
cases.  H.  M.  W.  Gray  (Brit.  Med. 
Jour.,  Aug.  22,  1914). 

To  illustrate  the  value  of  anoci- 
association,  the  writer  offers  a  table 
of  all  hysterectomies  operated  on 
since  the  adoption  of  the  necessary 
technique.  Excluding  2  legitimate 
exceptions,  the  average  pulse  rate 
for  17  hysterectomies  the  evening  be- 
fore operation  was  89;  the  average 
pulse  rate  the  evening  after  was  80. 
Some  of  these  patients  were  very 
much  exsanguinated  by  prolonged 
hemorrhages  and  some  had  large 
tumors.  The  value  of  the  method 
seems  incontestable.  J.  M.  Wain- 
wright  (Penn.  Med.  Jour.,  Dec,  1914). 

The  writer  advises  that  glucose 
solution  be  given  as  a  routine  after 
every  operation  in  which  one  has 
reason   to   fear  more   than    the    ordi- 

nary amount  of  postanesthetic  shock; 
it  should  be  given  as  a  routine  in 
every  case  in  which  postoperative 
oral  feeding  may  be  difficult  or  in- 
sufficient for  a  considerable  period 
after  operation;  it  should  be  given 
as  an  emergency  measure  either  be- 
fore or  after  operation  for  the  relief 
of  an  existing  or  threatened  acidosis. 
Burnham  (Amer.  Jour.  Med.  Sci., 
Sept.,   1915). 

TREATMENT.— Raising  the  limbs  and 
body  in  such  a  way  as  to  cause  the  blood 
to  gravitate  .toward  the  head,  followed 
by  absolute  rest  and  quiet  in  the  recum- 
bent position,  and  the  external  application 
of  heat  (taking  care  that  the  skin  be  pro- 
tected by  the  blanket  or  that  the  water- 
bottles  or  bags  used  be  wrapped  in  cloths 
or  flannel,  lest  they  burn  the  patient) 
around  the  trunk  and  extremities,  are  the 
first  measures  to  be  resorted  to. 

Having   treated    6667   wound    cases, 
the  writer  divides  shock  cases  into  3 
major    groups,   viz.,   nervous,    hemor- 
rhagic,  and   toxic.     A   group   apart   is 
that   by   exposure  or   exhaustion.     Of 
103  cases  of  hemorrhagic  shock  oper- 
ated upon  at  once,  96  recovered,  tend- 
ing to  show  the  advisability  of  imme- 
diate operative  hemostasis  in   hemor- 
rhage  cases,   whether   shock   is    or    is 
not  present  at  the  same  time.     Under 
nervous  shock  are  placed  concussion, 
multiple    wounds,    or    extensive    con- 
tusions.     In    these,    the    system    has 
reached   the   extreme   limit   of   its   re- 
sisting powers  and  treatment  is  often 
disappointing.     In   4   cases    of    grave 
nervous    shock,    however,    expectant 
treatment  and  postponement  of  oper- 
ation were  followed  by  recovery.     In 
toxic   shock  from  absorption,   an   op- 
portunity   for    recovery     is    afforded 
only  by  prompt  removal  of  the  toxic 
tissues.     Of  13  cases  thus  treated,  all 
recovered.      Gatellier     (Presse    med., 
Jan.  17,  1918). 
Adrenalin  has   to  a  considerable   extent 
replaced    all    other    stimulants    when     in- 
jected in  conjunction  with  saline  solution 
into   the    arterial   sytem — for  rapid   action 
— or  into  the  veins.     Its  effect  ma3^  how- 
e\  er,      be      evanescent.       Two     important 
measures  developed  and  found  serviceable 



during  the  late  war  v/ere,  intravenous  in- 
jection of  6  per  cent,  gum  acacia  solution 
to  cause  a  persistent  rise  in  the  blood- 
pressure,  and  the  removal  of  lacerated  or 
crushed  tissues  to  obviate  shock  from 
toxic  absorption. 

Locke's  solution  plus  3  per  cent,  of 
gum  acacia  used  with  success  in  the 
treatment  of  low  blood-pressure  from 
hemorrhage  and  shock.  If  there  has 
been  great  loss  of  blood,  the  Locke 
must  be  preceded  I:)y  an  infusion  of 
normal  saline  or  sugar  solution  to 
give  the  heart  fluid  to  pump  on,  the 
mucilaginous  Locke  solution  not  be- 
ing given  in  amounts  exceeding  150 
c.c.  (5  ounces).  Delaunay  (Lyon  chir., 
Jan.-Feb.,  1918). 

In  shock  the  catalase  of  the  blood 
and  probably  of  the  tissues  is  de- 
creased, owing  to  diminished  output 
of  it  from  the  liver  and  probably  to 
dilution  of  the  blood.  Alcohol  in 
shock  greatly  increases  the  catalase 
of  the  blood  and  tissues  by  stimu- 
lating the  liver  to  increased  output. 
The  beneficial  effect  of  alcohol  in 
shock  and  general  depression  is  due 
to  the  increase  it  causes  in  the  cata- 
lase of  the  blood  and  tissues,  with 
resulting  increase  in  oxidation  and 
decrease  in  acidosis.  Burge  and  Neill 
(Amer.  Jour,  of  Physiol.,  Feb.,  1918). 

Shocked  patients  should  be  placed 
in  the  quietest  available  quarters, 
kept  darkened,  with  comfortable  beds. 
The  bed  may  be  warmed  with  a 
cradle  heated  by  electricity  or  an 
alcohol  lamp.  The  arterial  pressure 
should  be  taken  every  hour.  Mor- 
phine is  given  regularly  as  it  seems 
efifective  in  raising  the  blood-pressure. 
Subcutaneous  injections  of  saline 
solution  with  adrenalin  complete  the 
treatment,  and  the  patient  sleeps. 
When  the  blood-pressure  has  im- 
proved to  40  and  70  or  80  mm.  Hg, 
then  operation  is  to  be  considered. 
Necessity  for  local  as  well  as  gen- 
eral anesthesia  emphasized.  Monery 
and  Loml^ard  (Arch,  de  med.  et  de 
pharni.  milit..  Mar.,  1918). 

Primary  shock  tends  to  lessen 
hemorrhage,  and  if  the  patient  is 
kept  warm  and  quiet,  the  Idood-pres- 

sure  may  return  to  normal.  Partial 
recovery,  however,  may  be  followed 
by  secondary  shock.  The  best  ex- 
planation of  this  is  an  accumulation 
and  stasis  of  blood  in  the  capillaries 
— Cannon's  cxoiiia.  As  a  result  the 
tissues  sufifer  from  oxygen  starvation 
and  the  vasomotor  and  respiratory 
centers  tend  to  fail.  Acidosis  is  not 
a  serious  factor  in  shock.  It  has 
not  yet  been  demonstrated  that  the 
symptoms  relieved  by  sodium  bicar- 
bonate would  not  be  more  definitely 
cured  by  raising  the  blood-pressure. 
The  main  factor  in  treatment  is  to 
ensure  an  adequate  supply  of  blood 
to  vital  organs.  A  solution  of  gum 
arabic  (acacia)  injected  intraven- 
ously in  most  cases  is  not  inferior  to 
blood.  A  6  per  cent,  solution  of  the 
gum  is  best,  with  0.9  per  cent,  of  com- 
mon salt.  Tliis  maintains  the  blood- 
pressure  indefinitely.  Its  value  is 
most  strikingly  demonstrated  after 
hemorrhage,  though  after  grave 
hemorrhage  blood  transfusion  is  the 
procedure  of  choice.  W.  M.  Bayliss 
(Brit.   Med.   Jour.,   May   18,   1918). 

Traumatic  or  wound  shock  is  due 
to  toxic  material  from  injured  tis- 
sues. If  the  blood-pressure  falls 
below  80  mm.  Hg,  the  tissues  begin 
to  sufifer  from  lack  of  oxygen.  In  the 
treatment,  arterial  pressure  should  be 
raised  by  blood  transfusion  if  it  per- 
sists below  this  critical  level.  Crushed 
tissue  should  be  removed  as  soon  as 
possible.  If  a  limb  is  shattered  and 
useless,  absorption  of  toxic  material 
may  be  prevented  by  a  tourniquet. 
Amputation  should  be  done  proxi- 
mate to  the  tourniquet  and  before  re- 
moving it.  Loss  of  body  heat  should 
be  checked  and  normal  temperature 
restored  by  application  of  heat. 
Since  ether  lowers  the  blood-pressure 
in  shock,  it  should  be  avoided.  Nit- 
rous oxide  and  oxygen  should  be 
used  in  a  ratio  not  exceeding  3  to  1, 
preceded  by  morphine.  Deep  anes- 
thesia and  cyanosis  should  always  be 
avoided.  W.  B.  Cannon  (Proceedings 
Amer.  Med.  Assoc,  N.  Y.  Med.  Jour., 
June  14,   1919). 

Crile's    technique    for    the    resuscitation 



of  a  patient  is  as  follows:  The  patient, 
in  the  prone  position,  is  subjected  to 
rapid  rhythmic  pressure  upon  the  chest, 
with  one  hand  on  each  side  of  the  ster- 
num, to  produce  artificial  respiration  and 
promote  circulatory  activity.  A  cannula 
being  then  inserted  into  an  artery,  toward 
the  heart,  normal  saline  solution  (2  tea- 
spoonfuls  of  sodium  chloride — being  care- 
ful not  to  use  the  non-deliquescent  table 
salt  now  commonly  employed — to  the 
quart  of  warm  water)  is  infused  through 
a  funnel  connected  with  the  ruliber  tub- 
ing connected  with  the  cannula.  As 
soon  as  the  flow  has  begun,  15  to  30 
minims  (0.9  to  1.8  c.c.)  of  adrenalin 
chloride  (1:1000)  are  injected  at  once 
with  a  hypodermic  syringe  plunged  into 
the  rubber  tubing,  i.e.,  into  the  saline 
solution,  repeating  the  dose  in  a  minute 
if  needed.  The  rhythmic  pressure  on  the 
thorax  being  exerted  with  maximum  ac- 
tivity, plus  the  powerful  contraction  of 
the  arteries,  including  the  coronaries, 
caused  by  the  infusion,  promptly  provokes 
a  powerful  rise  of  blood-pressure.  When 
this  attains  about  40  mm.  the  heart  re- 
sumes its  action,  its  contractions  steadily 
increasing  in  vigor.  As  soon  as  the 
cardiac  beats  are  fairly  resumed,  the 
cannula  should  be  withdrawn;  otherwise 
the  marked  increase  of  vascular  tension 
will  drive  a  torrent  of  blood  into  the 
tube.  Pituitary  extract  in  1:10,000  solu- 
tion seems  to  sustain  the  effect  on  heart 
and  circulation  longer  than  adrenalin. 

An  important  feature  of  arterial  or 
venous  infusion  is  that  it  should  not  be 
given  rapidly;  otherwise  an  excessive 
amount  of  fluid  will  suddenly  accumulate 
in  the  right  ventricle,  and  the  heart,  al- 
ready feeble,  will  cease  altogether  to 

In  prolonged  shock,  high  enteroclysis 
or  hypodermoclysis  of  saline  solution  is 
indicated.  Dawbarn  urged  that,  whenever 
possible,  the  solution  should  be  intro- 
duced into  the  median  basilic  vein,  but 
occasionally  a  vein  in  the  operating  wound 
will  answer  the  purpose,  or,  if  necessary, 
the  solution  may  be  introduced  into  the 
common  femoral  artery  with  the  aid  of 
an  hypodermic  needle  attached  to  a  foun- 
tain syringe.  Next  in  order  of  efficiency 
to  intravenous   saline  infusions   are  those 

introduced  into  the  rectum.  Hypodermoc- 
lysis is  the  slowest  of  all  the  methods. 
The  proper  temperature  for  the  solution 
according  to  Dawbarn  is  about  150°  F., 
but  this  seems  high.  At  least  1  quart, 
and  sometimes  even  2  or  3  quarts,  may 
be  injected,  providing  the  precaution  is 
taken  to  introduce  the  solution  slowly. 
The  time  occupied  in  introducing  the  fluid 
should  never  be  less  than  ten  minutes  per 
quart.  The  employment  of  intravenous 
injections  before  or  at  the  beginning  of 
the  operation  is  not  good  practice,  since, 
by  increasing  the  blood-pressure,  it  en- 
courages free  hemorrhage. 

Valuable  for  intravenous  infusions  in 
shock  is  Ringer's  solution,  prepared  as 
follows: — 

IJ  Calcium    chloride..    V/>  gr.   (0.1  Gm.). 
Potassium  chloride.  1  gr.   (0.06  Gm.). 
Sodium    chloride...   90  gr.   (6.0  Gm.). 
Heater  1  qt.    (1000  c.c). 


Careful  asepsis  of  the  arm,  apparatus, 
and  solution  is  important;  also  the  exclu- 
sion of  all  air  from  the  tube  before  intro- 
ducing the  cannula.  The  solution  should 
be  free  from  solid  particles.  A  probe- 
pointed  cannula  should  always  be  used. 
The  temperature  of  the  solution  should 
be  about  100°  F.;  hotter  solutions  are  of 
greater  value  as  a  stimulant;  an  initial 
temperature  of  108°  to  110°  F.  is  well 
borne.  The  fluid  is  cooled  from  one  to 
two  degrees  by  entering  the  cannula.  The 
amount  of  the  solution  to  be  injected  at 
one  time  varies  with  the  rapidity  of  the 
injection  and  with  the  quality  and  ten- 
sion of  the  pulse;  1  quart,  repeated  when 
necessary,  is  generally  better  than  a  large 
amount  given  at  one  time.  It  is  of  great- 
est value  in  shock  accompanied  by  hem- 
orrhage. In  threatening  cases  of  this 
class  direct  blood-transfusion  should  be 
resorted  to. 

As  regards  medical  treatment,  Senn 
recommended  the  inhalation  of  nitrite  of 
amyl,  and  the  administration  of  stimu- 
lants, such  as  alcohol,  hot  coffee,  and  tea. 
Of  alcoholic  stimulants,  hot  red  wine, 
rum,  and  brandy-punch  deserve  the  prefer- 
ence. Alcohol  in  small  doses  tends  to 
raise  the  blood-pressure  by  promoting 
oxidation  and  therefore  metabolism  in 
the  muscular  layer  of  the  arteries. 



Opium  is  contraindicated  in  the  treat- 
ment of  uncomplicated  shock,  but  atropine 
is  recommended  by  J.  C.  Da  Costa,  par- 
ticularly   when    the    skin    is    very    moist. 

Subcutaneous  injections  of  sterilized 
camphorated  oil  is  a  valuable  cardiac 
stimulant,  3  or  4  hypodermic  syringefuls 
being  administered  every  fifteen  minutes 
until  reaction  sets  in.  Digitalis  may  be 
used,  but  it  acts  slowly  in  an  emergency. 
Strophanthin,  using  the  1  c.c.  (16  minims) 
of  the  1:1000  solution  in  sterile  ampoules 
is  far  more  effective.  It  should  be  remem- 
bered that  in  shock  the  absorption  of  all 
drugs  administered  by  the  stomach  or 
rectum,  or  even  injected  into  the  tissues, 
is  always  slow;  hence,  care  is  necessary 
to  guard  against  cumulative  action  during 
the  recovery  of  the  patient. 

Research   showing    that    epinephrin 
has  no  cumulative  action.     Its  action 
occurs   only   on   direct  contact.     The 
continual  infusion  of  a  weak  solution 
of    epinephrin    may    prove    a    useful 
measure   in   therapeutics.     It   is   thus 
possible  to  send  the  solution  continu- 
ously  into  a  vein   and   thus  keep  up 
the  blood-pressure  permanently  while 
this   is    being  done — the   effect  being 
dependent    on    the    concentration    of 
the    solution,    not    on    the    absolute 
amount  of  epinephrin  infused.    Straub 
(Mimch.  med.  Woch.,  June  Zl ,  1911). 
Adjuvant  measures,  such  as  the  inhala- 
tion of  oxygen,  mustard  plasters  over  the 
heart,   the   spine  and   shins;   an   enema   of 
turpentine,  hot  coffee,  whisky  or  brandy; 
Esmarch    bandages    around    the    legs    and 
arms  or  a  tight  abdominal  binder  to  drive 
the    blood    toward    the    vital    organs    and 
increase    the    general    blood-pressure,    are 
all    helpful.      Crile    deems    an    increase   of 
peripheral   vascular  resistance   advantage- 
ous and  places   his  patient  in  an   air-tight 
rubber   suit  which   he   inflates   with   an  air 
pump,     thus     insuring     equable     pressure 
upon   the    entire   cutaneous    surface.     Ab- 
dominal massage  to  favor  the  better  dis- 
tribution   of    blood    from    deeper    vessels, 
followed  by  the  application  of  the  abdom- 
inal   binder    referred    to    above,    has    been 
lauded  as  an  efficient  measure.    Galvanism 
of  the  phrenic  has  been  used  to  promote 
contraction   of   the   diaphragm   and   there- 
fore excite  respiratory  activity. 

ELECTRICAL       SHOCK.— The       two 

main  causes  of  death  from  shock  due  to 
electrical  currents,  as  stated  by  Spitzka, 
Stanton  and  Krida  and  others  are  cardiac 
fibrillation  and  respiratory  paralysis.  The 
cessation  of  respiration  is  a  secondary 
phenomenon,  however,  though  usually 
simultaneous  with  cardiac  arrest.  Com- 
mercial low-tension  currents  tend  to  kill 
chiefly  by  producing  cardiac  fibrillation. 
As  the  tension  is  increased  the  effect  upon 
the  heart  becomes  less  pronounced,  but 
at  the  same  time  the  effect  upon  the 
central  nervous  system  becomes  more  and 
more  certain  as  the  tension  is  increased; 
so  that  with  high-tension  currents  death 
is  more  likely  to  be  caused  by  respiratory 
failure,  although  if  the  contact  is  pro- 
longed the  heart  is  also  stopped.  All 
evidence  points  to  the  central  nervous 
system  as  being  the  chief  sufferer  from 
the  effects  of  currents  of  more  than  4800 

Treatment. — Even  in  cases  of  good 
contact,  as  with  a  high-tension  current, 
according  to  Spitzka,  there  may  be  no 
heart  paralysis,  but  only  respiratory  fail- 
ure, and  in  such  cases  respiration  may  be 
re-established  spontaneously  or  artifici- 
ally. The  prognosis  is  good  only  in  cases 
in  which  there  is  some  heart  action  and 
respiration,   the  former,   particularly. 

The  stricken  individual  must,  of  course, 
be  taken  out  of  the  circuit,  if  he  be  not 
already  freed  from  it.  Bystanders  can 
do  this  with  rubber  gloves,  or  with  hands 
wrapped  with  thick,  dry,  woolen  material, 
by  pulling  at  the  victim's  clothing,  by 
sticks  of  wood,  or,  if  in  contact  with  a 
wire,  this  may  be  cut  with  a  nipper  with 
insulated  handles.  This  must  be  done 
with  caution,  as  the  momentary  arc 
formed  between  the  separated  ends  may 
blind  the  rescuers. 

The  patient  should  be  laid  with  the 
head  a  little  higher  than  the  body,  and 
artificial  respiration  be  begun  promptly  by 
compressing  the  thorax  about  18  times 
a  minute,  with  the  hands  applied  flat  to 
the  sides  and  lower  part  of  the  chest. 
The  tongue  must  be  drawn  forward,  or 
the  pulmotor  may  be  used  if  available. 
Massage  over  the  heart,  faradization,  the 
electrodes  applied  to  the  neck  ami  heart 
region,   or   adrenalin    injection   by    Crile's 


method,  may   be   used  to   stimulate   heart  silver    nitrate    with  2   parts   of   potas- 

action.    The  epiglottis  may  be  tickled  with  gj^^^     nitrate,     stirring     and     pouring 

the  forefinger.     Other  methods  that  have  .^^^^    ^^^^jj^_      j^    ^^^^^^    ^^    ^    ^^. 

been      suggested     are     lumbar     puncture,  ,         .  ,        .  ,                    .... 

venesection,  the  application  of  the  Leduc  '^ard  solid,  with  properties  Similar  to 

current,    and,   in   the    last    resort,    a   high-  those    of    the    preceding    preparation, 

tension  shock  of  short  duration.            S.  It    is   sohible   in   water,  but   the   con- 
tained   66.7    per    cent,    of    potassium 

SILVER.— Silver     (argentum)     in  ,^5^,.^^^   jg   ^j^jy   sparingly    soluble   in 

its   pure    metallic   state   has   a   white  alcohol.     Used  externally, 

color  and  a  high  degree  of  luster.     It  Argcnti    o.vidum,    U.    S.    P.    (silver 

is  unafifected  by  oxygen  or  moisture,  ^^-^^^^   [AgoO],  occurring  as  a  heavy, 

but    is    readily   attacked   by    sulphur,  brownish-black   powder,   with   a   me- 

and    tarnishes    when    exposed    to   air  ^^,jj^  ^^^^^      j^  -^  U^l^l^  ^^  reduction 

containing   hydrogen   sulphide.      The  ^^^    exposure    to    light.      It    is    very 

metal  itself  is  not  official,  but  is  used  slightly  soluble  in  water,  to  which  it 

at  times  in  a  colloid  state  in  unofficial  ji^^parts  an   alkaline   reaction,   and   is 

preparations.    Of  its  salts,  the  nitrate  ij^goiubig   i^   alcohol.     Dose,   :^    to  2 

is  most  largely  used.  grains  (0.03  to  0.13  Gm.)  ;  average,  1 

PREPARATIONS    AND    DOSE,  grain  (0.065  Gm.). 

— Argcnti  nitras,  U.   S.  P.   (silver  ni-  Argcnti   cyanidum,    U.    S.    P.    VIII 

trate)    [AgNOs],  occurring  in  color-  (silver  cyanide)    [AgCN],   occurring 

less,    rhombic    plates,    with    a    bitter,  as  a  white,  odorless  and  tasteless  pow- 

caustic,  metallic  taste.     It  is  soluble  der,  gradually  turning  brown  on  expos- 

in  0.54  part  of  water,  and  in  24  parts  ure  to  light,  insoluble  in  water  and  in 

of  alcohol.     It  melts  at  200°  C.    It  is  alcohol.     Formerly  used  in  the  prepar- 

rapidly  reduced  by  organic  matter  in  ation  of  diluted  hydrocyanic  acid, 

the  presence  of  light,  becoming  gray  Among  the   unofficial   preparations 

or    grayish    black.      Dose,    ^    to    ^  of  silver  are  the  following: — 

grain  (0.007  to  0.03  Gm.).  ^    Silver    citrate     [AggCoHgOT],    oc- 

Argcnti     nitras    ftisus,     U.     S.     P.  curring    as    a    white,    heavy    powder, 

(molded    silver    nitrate,    lunar    caus-  soluble  in   3800   parts   of  water,   and 

tic),   prepared   by   melting   silver   ni-  sensitive    to   light.      It   is   considered 

trate   with   ^5   its   weight   of  official  non-irritating,   and   has  been   applied 

hydrochloric  acid,  stirring,  and  pour-  in  substance  as  antiseptic  to  wounds 

ing   into    suitable    molds.      It   occurs  and  ulcers,  and  injected  in  solutions 

as    a    white,    hard    solid,    usually    in  of   1 :  4000  to   1 :  10,000  strength  into 

cones  or  pencils,  with  a  caustic  taste,  the  urethra,  etc. 

and  becomes  grayish  on  exposure  to  Silver  lactate  [AgC3H503  +  H20], 

light   and   organic   matter.      It   is   in-  occurring  in  crystalline  needles,  solu- 

completely   soluble   in   water   and    in  ble  in  15  parts  of  water,  and  turning 

alcohol,  the  contained  5  per  cent,  of  brown   on   exposure   to    light.      Used 

silver  chloride  remaining  undissolved,  externally   (though  irritating)   for  its 

Used  externally.  powerful  antiseptic  effect  in  1 :  100  to 

Argenti   nitras   mitigattis,    U.    S.    P.  1 :  2000  solutions. 

VIII  (mitigated  silver  nitrate;  mitigated  Albargin     (gelatose     silver).       See 

lunar    caustic),    prepared    by    melting  Albargin  in  the  second  volume. 



Argentamin  (ethylene-diamine  sil- 
ver nitrate),  a  solution  of  1  part  each 
of  silver  nitrate  and  ethylene-diamine 
[CHo(NH2)CH2(NH2)]  in  parts  of 
water,  A  colorless,  alkaline  fluid, 
turning  yellow  on  exposure  to  light. 
Asserted  to  be  non-irritant  and  more 
penetrating  than  silver  nitrate,  owing 
to  the  albumin-solvent  action  of  the 
containing  ethylene-diamine.  Used 
in  the  urethra  in  0.25  to  4  per  cent, 
solution,  and  in  ophthalmology  in  5 
per  cent,  solution. 

Argonin  (silver  casein),  prepared 
by  precipitating  an  alkaline  solution 
of  casein  with  silver  nitrate  and  al- 
cohol. A  fine,  nearly  white  powder, 
containing  4.28  per  cent,  of  silver, 
easily  soluble  in  water,  forming  an 
opalescent  solution  which  clears  on 
addition  of  sodium  chloride.  Used  as 
silver  nitrate,  generally  in  0.5  per 
cent,  solution. 

Argyrol  (silver  vitellin),  said  to  be 
prepared  by  electrolysis  of  serum 
albumin,  addition  of  moist  silver 
oxide,  heating  the  mixture  under 
pressure,  and  drying  in  I'acuo.  It  is 
probably  a  compound  of  hydrolyzed 
protein  and  silver  oxide,  and  contains 
from  20  to  25  per  cent,  of  silver.  It 
occurs  in  black,  shining,  hydroscopic 
scales,  freely  soluble  in  water  and 
glycerin,  but  insoluble  in  alcohol  and 
oils.  It  is  not  affected  by  boiling.  It 
is  incompatible  with  acids,  and  most 
neutral  or  acid  salts  in  strong  solu- 
tion. Used  as  a  non-irritant  anti- 
septic in  5  to  25  per  cent,  solutions 
in  urethritis,  cystitis,  and  diseases  of 
the  mucous  membranes  of  the  eye, 
ear,  nose,  and  throat. 

Hegonon  (silver  nitrate  ammonia 
albumose),  obtained  by  treating  sil- 
ver ammonium  nitrate  with  albumose. 
A   light-brown  powder,  readily   solu- 

ble in  water,  said  to  contain  about  7 
per  cent,  of  organically  combined  sil- 
ver. Used  as  substitute  for  silver 
nitrate  for  irrigation  purposes  in 
1 :  2000  to  1 :  6000  solutions. 

Ichthargan  (silver  ichthyolate  or 
ichthyosulphonate),  prepared  by  neu- 
tralization of  ichthyolsulphonic  acid 
with  silver  oxide,  and  extraction  with 
water.  A  brown,  stable  powder,  with 
a  light  chocolate-like  odor,  asserted 
to  contam  30  per  cent,  of  metallic 
silver  and  15  per  cent,  of  sulphur  in 
organic  combination,  freely  soluble 
in  water,  but  incompatible  with 
soluble  chlorides.  It  is  said  to  com- 
bine the  bactericidal  action  of  silver 
with  the  penetrating,  antiphlogistic 
action  of  ichthyol.  Used  in  0.04  to 
0.2  per  cent,  solution  in  gonorrhea ; 
3  per  cent,  solution  in  posterior  ure- 
thritis, and  in  0.5  to  3  per  cent,  solu- 
tion in  trachoma. 

Protargol  (protein  silver  salt),  pre- 
pared by  treating  proteins  with  a 
silver  salt,  and  rendered  soluble  by 
treatment  with  a  solution  of  albu- 
moses.  A  light-brown  powder,  con- 
taining 8.3  per  cent,  of  silver  in 
organic  combination,  soluble  in  2 
parts  of  water.  The  solution  is  not 
affected  by  alkalies,  chlorides,  bro- 
mides, or  iodides,  nor  by  heat.  Its 
precipitation  by  cocaine  hydrochlo- 
ride is  pre-vented  by  addition  of  boric 
acid.  It  should  not  be  exposed  to 
light.  Used  as  substitute  for  silver 
nitrate  for  irrigation  purposes  in 
1  :  1000  to  1  :  2000  solutions,  in  0.25 
to  1  per  cent,  solutions  in  acute  gon- 
orrhea, and  in  5  to  10  per  cent,  in- 
stillations in  chronic  gonorrhea,  and 
in  diseases  of  the  mucous  membranes 
of  the  eye,  ear,  nose,  and  throat. 

Colloid  silver  and  its  action  and 
therapeutic  uses  have  been  discussed 



under  the  heading  Collargol,  in  the  Where  silver  nitrate  is  to  be  used 

third  volume,  to  which  the  reader  is  locally  at  intervals  in  the  form  of  a 

referred.  solution,  addition  of  spirit  of  nitrous 

INCOMPATIBILITIES.  —  Silver  ether  is   considered  of  value   in   pre- 

nitratc   is   incompatible  with   organic  venting  precipitation.     The  following 

material,  becoming  transformed  into  formula     is     credited     to     Fox     and 

the    black    oxide    of    silver    or    black  Higginbotham  :— 

metallic    silver.       With    soluble    chlo-  ^  Argenti    nitratis    gr.  v  (0.3  Gm.). 

rides    or   hydrochloric   acid    it    forms  Spiritus  athcris  nitrosi  fSij    (8  c.c). 

the    insoluble    silver    chloride.      It    is  Aqncc  destillatce f3vj   (24  c.c). 

also  incompatible  with  bromides  and 

iodides,  with  alkalies,  with  acetates,  Such  a  solution  may  be  applied 
chromates,  cyanides,  hypophospites,  freely  to  the  conjunctiva,  without 
phosphates,  sulphides,  sulphates,  and  neutralization  with  salt  solution,  in 
tartrates,  with  copper  salts  and  fer-  all  forms  of  conjunctivitis,  from  a 
rous  and  manganous  salts,  with  "^i'd  "pink  eye"  to  gonococcal  con- 
antimony  salts  and  arsenites,  with  junctivitis  (Valk). 
morphine  salts,  with  alcohol,  with  Where  it  is  desired  to  use  an  oint- 
creosote,  with  oils,  and  with  tan-  *"ent  of  silver  nitrate,  the  following 
nic  acid  and  vegetable  astringent  combination  may,  with  advantage, 
preparations.  be  employed  :— 

MODES    OF   ADMINISTRA-  ^  Argenti  nitratis  gr.  xv  (1  Gm.). 

TION.-Silver    nitrate,     when     used  Acidi  borici  pulveris..  '^n.s  {li)  Gm.), 

,,       .                   ,       '   .           .         .„  Cerce  flava: Sj   (30  Gm.). 

mternally,  is  generally  given  in  pills,  q^^.  ^^-^^  ^^..   ^^^  ^^^ 

but   may    also   be   administered   in  a  yi^ 

solution    of    0.2    per    cent,    strength,  c^.,              •,      .                  ,,         ,     •   • 

-      ,  ,      ,          ,                    ,       ,  Silver  oxide  is  generally  adminis- 

preterably  through  a  stomach-tube  to  ^        .  .        .,,   , 

, ,        ■'  .   .      .          ,     ,        .,         ,  tered  in  pill  form, 

avoid  precipitation  of  the  silver  be-  ^,       ,<           .  ,,      ., 

,          .             ,           ,                 .            .  ihe      organic      silver    compounds, 

tore    It    reaches    the    gastric    cavity.  ,                            ,         , 

,,,,           ,            .            ."     ,       ,,  such    as    protargol    and    argyrol,    are 

When    thus    given,    it    should    soon  ,       .         n                  ,,     .         ,     • 

r,       ,                     ,   ,       ,                 r-.,  used  externally,  generally  in  solution, 

after  be  removed  by  lavage.     Silver  .^      i_  i              i      ^-i 

.      ^         ...        ,       ,,    ,              ,          .  ,  (bee  below,  under   i  herapeutics.) 

nitrate    pills    should    be    made    with  ^ 

kaolin    or    petrolatum,     as    glucose,  PHYSIOLOGICAL     ACTION. - 

glycerin,  extracts  and  other  materials  Locally,    silver    nitrate    is    antiseptic 

commonly  used  as  excipients  render  ''^"^  ^'^'y  irritating.     It  is  astringent, 

the'  salt  inert.     The  following  form-  coagulating  proteins,  and  also  caustic, 

ula    for   silver-nitrate   pills    has   been  ''^^d^'y   destroying   soft    tissues   with 

recommended: which    it    is    brought    in    immediate 

■D    ^        ,.     .,    ,.                  ,o/  /rM  ^     A  contact     in     concentrated     form.      It 
tfi  Argenti  mtratis   ....   gr.  1%  (0.1  Gm.). 

c«^;;     c.w/,/,^/;,.    .^  coats    moist    tissues    with    a    tough. 

iioaii     sulpliatis     ex-  ^ 

siccati  gr.  viij  (0.5  Gm.).  ^^ite      film,      and      has     not     much 

KaoUni •. gr.  xv  (1  Gm.).  penetrating  power,  though  Wildbolz 

Aqua  destiUata:  gtt.  x.  found    1:1000   to    1:100   solutions    to 

Fac.  in,  pilulas  no.  xx.  penetrate   to   the   subepithelial   tissue 

(Each  pill  contains  V12  grain^^.005  Gm.—  in  the  urethra  of  the  dog.     In  dilute 

of  the  silver  salt).  solution    it    overcomes    relaxation    of 



tissues,  and  apparently  improves 
local  nutrition.  Its  local  action,  if 
excessive,  can  be  quickly  arrested 
with  a  solution  of  sodium  chloride, 
which  precipitates  it  as  silver  chlo- 
ride. Applied  to  the  skin,  it  produces 
a  brown  and,  later,  a  black  stain,  on 
exposure  to  light. 

The  "organic"  preparations  of  sil- 
ver, such  as  argyrol  and  protargol, 
are  not  precipitated  by  protein  and 
sodium  chloride,  and  are  not  astrin- 
gent. Protargol  is  but  slightly  irri- 
tant, as  compared  to  silver  nitrate, 
and  argyrol  hardly  irritant  at  all. 
Their  efficiency  as  antiseptics  is, 
however,  far  less  than  that  of  silver 
nitrate,  for  which,  in  spite  of  their 
low  irritant  power,  they  are  not, 
therefore,  adequate  substitutes  where 
a  strong  antiseptic  action  is  desired. 
Post  and  Nicoll  found  the  gonococcus 
killed  in  one  minute  by  1  :  5000  silver 
nitrate,  but  only  partially  inhibited  in 
the  same  period  by  10  per  cent,  pro- 
targol, and  hardly  at  all  influenced 
by  10  per  cent,  argyrol.  Similar  re- 
sults were  obtained  in  the  case  of  the 
pyogenic  streptococcus  and  the  pneu- 
mococcus,  except  that  a  1  :  1000  silver- 
nitrate  solution  was  required  to  kill 
these  organisms  in  one  minute.  The 
typhoid  organism,  on  the  other  hand, 
was  killed  in  one  minute  only  by  a 
1  per  cent,  silver-nitrate  solution, 
though  succumbing  completely  in 
the  same  period  to  10  per  cent, 
argyrol  or  protargol.  The  antiseptic 
action  of  silver  nitrate  is  due,  not 
only  to  coagulation  of  the  protein  of 
the  bacteria,  but  also  to  a  specific 
action  of  the  metal,  silver  proteinate 
itself  being  antiseptic. 

The  bluish-white  pellicle  which  fol- 
lows the  application  of  silver  nitrate 
to  the  conjunctiva  is   not  coagulated 

albumin,  but  chloride  of  silver  de- 
posited in  the  structure  of  the  mem- 
brane. The  essential  element  in 
determining  the  stain  is  the  soluble 
chlorides  of  the  tissues.  It  is  chlo- 
ride of  silver  that  is  decomposed  by 
light,  not  albuminous  material.  The 
brown  stain  is  either  argentous  chlo- 
ride or  an  oxychloride  of  silver. 
Drops  of  silver-nitrate  solution  are 
more  potent  in  causing  a  stain  than 
an  application  of  a  stronger  solution 
by  the  brush. 

The  penetration  of  a  20  per  cent, 
solution  of  argyrol  as  compared  with 
weak  silver  nitrate  is  practically  nil. 
The  amount  of  silver  organic  silver 
compounds  contain  is  no  criterion  of 
their  therapeutic  utility.  Argyrol  may 
have  a  mechanical  effect,  and  its 
sedative  action  is  due  to  the  large 
amount  of  silver  it  contains,  metallic 
silver  being  sedative  in  its  action. 
Burden  -  Cooper  (Ophthalmoscope, 
Jan.,  1907). 

Silver  acetate  forms  a  durable  solu- 
tion and  has  the  least  irritating  action 
on  the  tissues  of  all  the  silver  salts. 
It  is  strongly  bactericidal.  It  is  im- 
portant to  follow  its  application  by 
rinsing  with  water  or  with  a  weak 
salt  solution.  Schweitzer  (Archiv  f. 
Gynak.,  Bd.  xcvii,  nu.  1,  1912). 

Silver  nitrate  dissolved  in  water 
killed  the  dysentery  bacillus  in  five 
minutes.  On  the  other  hand,  in 
broth,  with  the  addition  of  a  little 
organic  matter  and  salts,  it  failed  in 
a  strength  of  1  in  100.  The  frequent 
failure  of  silver-nitrate  injections  in 
dysentery  is  thus  easily  understood. 
Albargin  gave  the  best  results  of  any 
of  the  silver  compounds  in  the  pres- 
ence of  broth,  as  it  killed  the  dysen- 
tery bacillus  within  five  minutes  in  a 
dilution  of  1  in  500,  but  it  was  less 
efficient  in  a  second  trial.  Collargol, 
ichthargan,  and  argyrol  had  little  or 
no  action  in  the  presence  of  broth. 
Rogers  (Indian  Jour,  of  Med.  Re- 
search, Oct.,  1913). 

General  Effects. — Taken  internally 
in  moderate  dosage,  silver  nitrate  has 



been  held  to  act  as  a  tonic  to  the 
nervous  system,  exert  a  favorable 
influence  on  the  blood,  and  promote 
constructive  tissue  metabolism,  but 
there  exists  no  delinite  pharmaco- 
logic evidence  supporting  these  views. 
Administered  subcutaneously  or  in- 
travenously in  poisonous  doses  in 
animals,  its  characteristic  effects  ap- 
pear to  be  primary  stimulation  of  the 
central  nervous  system,  especially  the 
medullary  centers,  followed  by  de- 
pression and  paralysis;  in  slower 
poisoning,  a  marked  increase  of  bron- 
chial secretion,  ending  in  edema  of 
the  lungs,  has  been  observed.  In 
cold-blooded  animals,'  silver  salts  are 
said  to  give  rise  to  convulsions  in 
some  ways  similar  to  those  of  strych- 
nine, followed  by  paralysis.  These 
effects  have  no  evident  therapeutic 
bearing.  Large  amounts  of  silver 
nitrate  taken  internally  produce,  by 
reason  of  their  caustic  action,  a  vio- 
lent gastroenteritis,  thrombosis  of  the 
gastric  veins,  and  ulceration  of  the 
gastric  mucosa. 

Absorption  and  Elimination. — It  is 
believed  that  in  man  the  greater  part 
of  the  silver  ingested  passes  through 
the  alimentary  tract  unabsorbed.  The 
remainder  is  apparently  absorbed  in 
the  form  of  a  solution — none  of  it  be- 
ing found  in  the  gastric  or  intestinal 
epithelia — and  is  soon  after  deposited 
in  the  tissues  in  minute  granules.,  be- 
lieved to  consist  of  an  organic  com- 
pound of  silver.  That  it  stays 
imbedded  thus  indefinitely  is  sug- 
gested by  the  fact  that  the  resulting 
pigmentation  remains  unaltered  over 
long  periods. 

Fraschetti  and  others  deny  that 
any  elimination  of  silver  takes  place 
in  man,  either  through  the  kidneys  or 
the  intestines. 

POISONING.— There    are    two 

forms  of  poisoning  by  silver — that 
following  a  large  single  dose  (acute), 
and  that  following  the  long-continued 
use  of  small  doses   (chronic). 

Acute  Poisoning. — The  symptoms 
of  acute  poisoning  by  silver  nitrate 
are  partly  gastrointestinal  and  partly 
cerebrospinal.  Either  series  of  phe- 
nomena may  predominate. 

Almost  immediately  after  a  poison- 
ous dose,  a  burning  is  felt  in  the 
throat  and  stomach,  and  soon  aftei' 
violent  abdominal  pain,  with  vomit- 
ing and  purging,  comes  on.  The  ab- 
dominal walls  may  become  hard  and 
knotted,  more  rarely  scaphoid.  The 
face  becomes  flushed  or  livid,  and  is 
covered  with  sweat.  The  expression 
is  one  of  anxiety.  When  vomiting 
occurs,  the  ejecta  are  often  brown  or 
blackish  in  color,  though  sometimes 
white  and  curdy,  especially  after 
sodium  chloride  has  been  given.  The 
lips  and  mouth  are  covered  with  a 
grayish-white  membrane,  which  may 
later  change  to  brown  and  then  black. 
Occasionally,  where  the  poison  has 
been  ingested  in  solid  form,  this 
membrane  is  absent. 

In  some  cases  the  nervous  symp- 
toms are  severe,  consisting  of  inco- 
ordination, paralysis,  and  convulsions 
with  coma  or  delirium.  The  convul- 
sions are  generally  tetanic,  persist, 
according  to  Rouget,  after  complete 
abolition  of  voluntary  movements, 
and,  according  to  Curci,  are  due  to 
excitation  of  the  motor  cells  of  the 

Collapse  follows,  because  of  the 
gastrointestinal  corrosion  produced, 
and  death  takes  place  from  asphyxia 
due  to  central  respiratory  paralysis, 
accompanied    by    a    profuse    flow    of 

bronchial     secretions. 





monary  edema.  In  a  case  reported 
by  Ueck  coma  returned  at  intervals 
during  several  days  before  the  patient 

At  post  mortem  the  stomach  and 
howels  are  found  corroded,  often 
ecchymosed,  and  with  patches  of  a 
w^hite  or  grayish  color.  The  lungs 
are  congested  and  the  bronchial  tubes 
filled  with  fluid. 

Poisoning  by  this  drug  is  not  com- 
mon. The  lethal  dose  is  not  certain ; 
30  grains  have  killed  and  recovery 
has  followed  the  ingestion  of  an 

Treatment  of  Acute  Poisoning. — 
The  chemical  antidote  is  common 
salt  (sodium  chloride),  which  should 
be  administered  in  large  amounts. 
Vomiting  should  then  be  induced  at 
once,  as  the  silver  chloride  formed  is 
soluble  in  solutions  of  sodium  chlo- 
ride and  in  the  digestive  fluids.  Lav- 
age of  the  stomach  with  a  very  soft 
stomach-tube  may  be  carefully  tried. 
If  the  stomach  cannot  be  washed  out, 
one  may  give  large  draughts  of  salt- 
water and  produce  vomiting  alter- 
nately. Opium  and  oils  may  be 
given  to  allay  the  irritation,  and 
large  draughts  of  milk  administered 
to  dilute  the  poison  and  protect  the 
mucous  membranes.  Mucilaginous 
fluids  and  white  of  egg  may  also 
be  used  as  demulcents.  External  heat 
should  be  applied  if  indicated,  and  in 
the  event  of  collapse,  the  customary 
stimulant  measures  availed  of,  to- 
gether with  artificial  respiration. 
Atropine  might  prove  of  value  to 
counteract  the  excessive  bronchial 

Chronic  Poisoning.- — Prolonged  in- 
ternal use  of  any  of  the  soluble  salts 
of  silver  gives  rise  to  chronic  poison- 
ing, or  argyria.     A  local  argyria,  or 

argyrosis,  may  be  caused  by  the  fre- 
quent topical  application  of  a  soluble 
silver  salt  for  a  prolonged  period. 
Discoloration  of  the  eyelids,  con- 
junctiva, and  cornea  has  been  ob- 
served from  the  use  of  silver  nitrate 
in  the  eye,  and  a  similar  condition 
noted  from  its  local  application  in  the 
throat,  or  a  blackening  of  the  hands 
from  constant  working  with  silver. 
A  few  cases  have  even  been  reported 
of  general  argyria  resulting  from 
topical  use  of  silver  in  the  mouth 
and  throat. 

General  argyria  was  formerly  more 
frequent  than  now,  arising  frequently 
from  the  administration  of  silver  ni- 
trate in  epilepsy.  The  first  sign  of  it 
is  the  appearance  of  a  slate-colored 
line  along  the  gums,  associated  with 
some  inflammatory  swelling.  Later 
grayish  spots  or  patches  appear  on 
the  skin  and  mucous  membranes,  and 
spread  over  the  whole  body  until  the 
skin  has  acquired  a  peculiar  bluish- 
slate  color,  which  may  become  very 
dark.  In  decided  cases,  the  conjunc- 
tiva and  oral  mucous  membrane  are 
involved.  In  some  cases  discolora- 
tion is  especially  marked  in  the  face. 
The  silver  is  found  in  all  the  tissues 
of  the  skin  below  the  rete  Malpighii, 
and  is  deposited  mainly  in  the  con- 
nective tissues,  the  various  paren- 
chymatous cells,  and  epithelia  of  the 
body  escaping  the  pigmentation.  Al- 
though the  discoloration  is  long  in 
making  its  appearance,  the  deposi- 
tion in  the  tissues  prol^ably  begins 
at  once,  gradual  accumulation  there- 
after taking  place.  Especially  marked 
deposition  occurs  in  the  renal  glo- 
meruli, the  hepatic  and  splenic 
connective  tissue,  the  mesenteric 
glands,  the  serous  membranes,  and 
the  choroid  plexus.     The  connective 



tissues  throughout  the  respiratory 
passages  and  alimentary  canal  like- 
wise show  silver  deposition.  The 
condition  of  argyria  does  not  seem 
to  affect  the  general  health. 

Two  women  were  workers  in  silver 
leaf,  their  task  being  to  cut  the  leaves 
and  lay  them  in  books.  One,  aged 
27,  had  wr  rkcd  steadily  for  fourteen 
years.  The  discoloration  of  the  skin 
was  first  noted  when  she  was  18,  and 
it  increased  steadily  for  four  years, 
then  remained  the  same.  It  affected 
chiefly  the  exposed  parts  and  visible 
mucosae.  The  other  patient,  50  years 
old,  had  begun  to  follow  the  occupa- 
tion at  14,  and  had  first  noticed  the 
discoloration  at  21.  Both  women 
exhibited  anemia  and  disordered  di- 
gestion several  years  before  the  ap- 
pearance of  the  argyrosis.  The  silver 
line  on  the  gums  should  be  watched 
for  as  a  danger  signal  in  subjects 
similarly  occupied.  Koelsch  (Miinch. 
med.  Woch.,  Jan.  30,  Feb.  6,  13,  1912). 

Argyria  has  been  induced  in  three 
months,  and  after  the  use  of  j/2  to  1 
ounce  (15  to  30  Gm.)  of  silver  nitrate 

Treatment  of  Chronic  Poisoning. — 
Prophylaxis  is  important.  When  the 
salts  of  silver  are  indicated  in  a  pro- 
longed course  of  treatment,  occa- 
sional discontinuance  of  the  remedy 
is  imperative.  At  the  end  of  the 
third  week,  the  remedy  should  be 
stopped  for  one  week,  and  after  three 
months  a  long  intermission  should 
follow.  In  the  intermissions  of  treat- 
ment, the  patient  should  receive  a 
thorough  course  of  purgatives,  diu- 
retics, and  baths.  Potassium  iodide 
may  be  given  with  the  silver  salts  to 
expedite  its  elimination. 

Greater  or  less  success  has  been 
claimed  for  various  treatments  in 
argyria,  but  in  general  they  are  futile. 
Rogers  claims  that  blistering  will 
lighten  the  color,  but  how  it  should 

do  so  is  not  plain,  since  the  silver 
deposit  lies  deep  down  in  the  skin. 
luchmann  recommends  the  use  of 
potash  baths  and  of  soap  baths,  each 
four  times  a  week.  The  internal  use 
of  potassium  iodide  may  produce 
some  change  in  the  color  of  the  skin, 
but  perfect  restoration  to  the  normal 
is  generally  unattainable. 

Report  of  the  case  of  a  young 
woman,  supposedly  suffering  from 
jaundice,  which  turned  out  to  be 
argyrism  following  a  course  of  col- 
largol.  A  dose  of  10  grains  (0.65 
Gm.)  of  hexamethylenamine,  given 
for  a  coryza,  caused  marked  improve- 
ment in  the  patient's  coloration.  A. 
M.  Crispin  (Jour.  Anier.  Med.  Assoc, 
May  2,  1914). 

THERAPEUTICS.  —  Gastrointes- 
tinal Disorders. — Silver  nitrate  has 
been  found  of  some  value  in  the 
treatment  of  gastric  ulcer.  It  is  often 
given  in  pill  form,  sometimes  in  com- 
bination with  extract  of  hyoscyamus 
or  opium.  As  hydrochloric  acid  or 
sodium  chloride  renders  it  inert  by 
precipitation  of  silver  chloride,  it  may 
prove  useless  unless  its  ingestion  is 
preceded  by  lavage  of  the  stomach. 
A  1  in  500  solution  of  it  may  then  be 
introduced  through  the  tube  to  the 
amount  of  Yi  fluidounce  (15  c.c),  and 
in  a  few  minutes  lavage  with  plain 
water  repeated.  The  dose  of  silver 
nitrate  in  pill  form  in  these  cases  is 
M  to  y2  grain  (0.015  to  0.03  Gm.). 
If  it  is  given  in  solution,  sodium  bi- 
carbonate may,  with  advantage,  be 

Pyrosis  is  frequently  relieved  by  1- 
grain  (0.065  Gm.)  doses  of  silver 
oxide,  given  in  pill  form,  a  half-hour 
before  meals. 

In  chronic  gastritis  and  gastric 
catarrh,  when  sour  eructations  or 
vomiting  occur  after   meals,   the  ni- 



trate  in  doses  of  %  to  H  grain  (0.01 
to  0.015  Gm.),  given  an  hour  before 
meals,  sometimes  yields  good  results. 
Forlanini  in  these  cases,  when  asso- 
ciated with  hyperchlorhydria,  irri- 
gates the  stomach  with  a  solution  of 
silver  nitrate,  10  to  30  grains  (0.6  to 
2  Gm.)  to  the  quart  (liter),  fol- 
lowed immediately  by  sodium  chlo- 
ride solution. 

Experiments  and  clinical  experi- 
ences showed  that  silver  nitrate  has 
the  property  of  increasing  the  acidity 
of  the  gastric  juice.  It  is  indicated 
in  hypochlorhydria  and  in  mucous 
gastric  catarrh.  It  aids  in  the  diges- 
tion of  protein.  The  drug  may  be 
used  to  advantage  in  abnormal  fer- 
mentation. It  promotes  the  empty- 
ing of  the  stomach.  These  various 
effects  were  observed  with  small 
doses  (%2  grain — 0.002  Gm. — three 
times  a  day),  as  well  as  with  large 
amounts  (^  grain — 0.03  Gm. — three 
times  a  day).  Baibakofif  (Archiv  f. 
Verdauungsk.,  Bd.  xii,  nu.  1,  1906). 

Catarrhal  jaundice  has  been  re- 
lieved by  i/^o-gi'ain  (0.005  Gm.)  doses 
of  silver  nitrate.  F.  Ehrlich  has 
recommended  (1902)  the  introduction 
of  a  1  per  cent,  solution  of  the  salt 
into  the  stomach,  after  preliminary 
lavage  with  warm  w^ater,  in  angio- 
cholitis,  cholelithiasis,  and  chole- 
cystitis. The  solution  is  withdrawn 
after  one-half  to  two  minutes,  the 
process  repeated,  and  washing  with 
j)lain  water  then  continued  until  a 
clear  fluid  returns.  The  remedy  is 
asserted  to  act  as  a  cholagogue  and 
to  relieve  the  symptoms,  sometimes 
after  preliminary  aggravation. 

Use  of  silver  nitrate  recommended 
in  all  irritative  conditions  of  the 
gastric  mucosa  with  increased  secre- 
tion, hyperacidity,  nausea,  vomiting, 
and  pain.  In  gastric  neuroses,  how- 
ever, the  drug  exerts  no  influence 
whatever.      In    the    hyperchlorhydria 

frequently     occurring     in     chlorosis, 

various  diseases  of  the  liver,  chole- 
lithiasis, cholecystitis,  the  early  stages 
of  nephritis,  and  reflexly  in  constipa- 
tion, especially  of  the  spastic  type, 
and  in  mucous  colitis,  treatment 
should  be  chiefly  directed  to  the  pri- 
mary disease,  but  for  the  alleviation 
of  the  symptoms  silver  nitrate  is 

In  benign  pyloric  stenosis  with  re- 
tention of  the  gastric  contents  and 
decomposition  of  the  retained  ingesta, 
the  most  efifective  symptomatic  treat- 
ment is  thorough  lavage  followed  by 
silver  nitrate  internally.  In  fissure  at 
the  pyloric  orifice,  lavage  followed  by 
silver  nitrate,  a  non-irritating  diet, 
and  olive  oil  on  an  empty  stomach, 
has  never  failed,  in  the  author's  ex- 
perience, to  effect  a  cure.  For  the 
pain  of  gastric  ulcer,  acute  or  chronic, 
silver  nitrate  is  superior  to  any  other 
drug.  The  heartburn,  sour  eructa- 
tions, headache,  and  constipation  are 
also  promptly  relieved. 

Silver  nitrate  is  always  well  borne 
by  the  stomach.  In  a  case  of  severe 
hemorrhage  from  gastric  ulcer  in 
which  the  patient  suffered  intensely 
from  sour  eructations  and  laryngeal 
spasm,  silver  nitrate  relieved  both 
these  symptoms  after  the  second 
dose.  In  chronic  acid  gastritis  silver 
nitrate  acts  as  in  other  forms  of  hy- 
peracidity. In  alcoholic  gastritis  dur- 
ing the  hj'peracid  stage  it  should  also 
be  employed.  It  is  important  in  all 
forms  of  gastritis  to  wash  the  stom- 
ach thoroughly  before  the  drug  is 

The  writer  usually  gives  the  drug 
in  solution  in  doses  of  J4  to  ^  grain 
(0.016  to  0.03  Gm.)  three  times  a  day 
on  an  empty  stomach.  No  food  or 
drink  is  followed  for  half  an  hour 
after  its  administration.  It  is  rarely 
necessary  to  continue  longer  than 
three  weeks,  though  in  rebellious 
cases  it  may  he  given  for  a  month 
without  danger  of  argyria.  Where 
the  intestines  react  unfavorably  it 
should  be  discontinued  at  once.  H. 
Weinstein  (N.  Y.  Med.  Jour.,  Dec. 
28,  1907). 



In  ulceration  of  the  cecum  or  rec- 
tum and  in  acute  and  chronic  dysen- 
tery, rectal  or  colonic  injections  of 
silver  nitrate  are  of  value.  If  the 
cecum  be  invohcd  a  large  bulk  must 
be  used  to  reach  the  seat  of  the 
trouble;  if  the  rectum  is  the  part 
affected  not  more  than  4  ounces  (120 
c.c.)  should  l)e  used.  In  either  case 
there  should  be  given  preliminary 
cleansing  injections  of  warm  w^ater. 
If  the  condition  is  cecal,  one  may  use 
1  dram  (4  Gm.)  of  silver  nitrate  to  3 
pints  (1500  c.c.)  of  water;  if  rectal, 
5  grains  (0.2  Gm.)  to  4  ounces  (120 

If  the  rectal  disturbance  is  chronic 
and  very  obstinate,  the  strength  may 
be  increased  to  5  grains  (0.3  Gm.)  of 
the  salt  to  4  ounces  of  water.  A 
solution  of  common  salt  should  be  at 
hand,  to  be  injected  if  the  action  of 
the  silver  is  too  severe,  or  to  stop 
the  action  of  the  remedy  when  the 
desired  effect  has  been  produced. 

The  antiseptic  and  astringent  prop- 
erties of  protargol  proved  effective  in 
several  cases  of  gastrectasia  with  py- 
loric stenosis,  the  fermentation,  py- 
rosis, and  vomiting  being  checked. 
Improvement  was  also  noted  in 
chronic  catarrh,  gastric  ulcer,  and 
even  in  carcinoma.  Several  cases  of 
dysentery  and  pseudodysentery  were 
rapidly  cured  by  intestinal  lavage 
with  a  2.6  per  cent,  solution  of  pro- 
targol. For  the  enteritis  of  children 
y2  to  %  pint  (25U  to  300  c.c.)  uf  a  2 
per  cent,  solution  were  employed. 
For  gastric  lavage  a  2  per  cent,  solu- 
tion is  used.  It  is  advisable  to  wash 
out  first  with  water,  then  to  intro- 
duce 1  quart  (liter)  of  the  protargol 
solution.  After  eight  or  ten  minutes, 
this  is  again  washed  out  with  water. 
For  intestinal  lavage,  a  preliminary 
washing  with  water  is  not  necessary. 
Cantani  (Gaz.  degli  osped..  No.  138, 

Nervous  Disorders.  —  Silver  has 
l)cen  used  in  anterior  and  posterior 
spinal  sclerosis,  and  in  epilepsy  and 
chorea,  Ijut  with  little  or  no  favorable 
eft'ect,  except  possibly  as  a  general 

In  tabes  dorsalis  Curci  has  claimed 
good  results  from  the  use  of  a  double 
salt,  the  thiosulphate  (hyposulphite) 
of  sodium  and  silver.  He  gives  daily 
from  %  to  3  grains  (0.048  to  0.2  Gm.) 
by  mouth  or  from  %  to  %  grain  (0.01 
to  0.048  Gm.)  hypodermically.  He 
asserts  that  this  treatment  does  not 
cause  argyria. 

Surgical  Disorders. — Fissures  of 
the  lips,  tongue,  nipples,  rectum,  and 
mucous  patches  and  ulcers  of  the 
mouth  yield  readily  to  applications 
of  a  60-grain  (4  Gm.)  to  the  ounce 
(30  c.c.)  solution  of  silver  nitrate 
applied  carefully  on  a  pledget  of 
cotton  or  by  means  of  a  camel's- 
hair  pencil.  In  some  cases  the  solid 
stick  does  better.  It  is  also  useful  in 
hemorrhage  from  leech-bites. 

Boils  and  felons  may  be  aborted 
Ly  early  application  of  a  strong  solu- 
tion of  silver  nitrate. 

The  healing  of  suppurating  ulcers 
and  wounds,  with  large  flal)by  granu- 
lations, is  hastened  by  an  application, 
every  day  or  two,  of  the  solid  stick 
or  strong  solution.  The  surface  of 
indolent  ulcers  may  be  touched 
lightly  with  the  solid  stick,  or  a  line 
may  be  traced  within  and  parallel  to 
the  margin  of  the  ulcer  every  day  or 
two,  the  ulcer  being  strapped  with 
diachylon  adhesive  plaster  during  the 
intervals  and  the  limb  dressed  with 
a  roller  bandage.  Indolent  sinuses 
from  buboes  or  from  abscesses  may 
likewise  be  stimulated  to  healing 
with  a  strong  solution  or  the  solid 



Powdered  silver  nitrate  recom- 
mended as  a  means  of  exciting  the 
proliferation  of  granulations  and  the 
regeneration  of  epidermis  over  open 
wounds  and  ulcers.  As  an  excipient 
the  writer  uses  fullers'  earth  (l)olus 
alba),  sterilized  by  heating  to  100° 
or  150°  C.  The  mixture  should  con- 
sist of  1  part  of  silver  nitrate  to  99 
parts  of  the  earth.  It  is  dusted  on 
the  raw  surface  (not  extending  over 
the  parts  already  healed  over),  and 
renewed  every  second  or  third  or 
fourth  day,  according  to  the  amount 
of  secretion  and  reaction  of  the  tis- 
sues. When  the  wound  is  well  on 
the  way  to  epidermization  the  treat- 
ment should  be  interrupted  from  time 
to  time  and  simple  aseptic  dressing 
applied.  The  treatment  is  recom- 
mended especially  for  burns,  and  for 
the  healing  of  wounds  following 
furuncles  and  other  infective  proc- 
esses of  the  skin.  Max.  Barnet 
(Miinch.  med.  Woch.,  Aug.  30,  1910). 

Bed-sores  can  sometimes  be  aborted 
ii,  as  soon  as  the  surface  reddens,  it 
is  brushed  over  with  a  20-grain  (1.3 
Gm.)  to  the  ounce  (30  c.c.)  solution 
of  silver  nitrate.  This  treatment  is, 
however,  frequently  of  no  avail  in 

Lymphangitis  of  the  forearm  re- 
sulting from  a  poisoned  wound  of 
the  finger  may  be  cured  by  applying 
the  solid  stick  over  the  lines  of 

Rovsing  prefers  silver  nitrate  to  all 
other  antiseptics  for  impregnating 
gauze  and  drainage  wicks,  and  in  the 
preparation  of  suture  material,  and 
uses  it  extensively  in  his  clinic  for 
these  purposes. 

Spasmodic  esophageal  stricture  lias 
been  relieved  by  the  use  of  a  sponge 
probang  saturated  with  a  very  weak 
solution  of  silver  nitrate. 

Gushing,  Halsted,  and  Lexer  highly 
recommend  the  use  of  silver  foil  as 

a  dressing  for  granulating  wounds, 
and  especially  for  skin-grafts  and  the 
incisions  in  plastic  operations  on  the 
face.  The  silver  leaf  acts  as  an  anti- 
Leptic  and  minimizes  scarring. 

The  marked  tolerance  of  the  body 
tissues  for  metallic  silver  has  led  to 
its  use  in  bone  suturing  and  in  the 
preparation  of  supporting  filigree  or 
chain  for  use  in  cases  of  ventral 
hernia  or  other  varieties  of  weakened 
abdominal  wall. 

Miller  recommends,  as  productive 
of  good  scar  formation  in  burns,  the 
use  of  an  ointment  of  protargol,  45 
grains  (3  Gm.),  dissolved  in  cold  dis- 
tilled water,  75  minims  (5  c.c),  and 
mixed  with  3  drams  (12  Gm.)  of  dried 
wool-fat  and  2^^  drams  (10  Gm.)  of 

Silver  -  foil  platelets  used  over 
wounds  where  very  inconspicuous 
scar  is  desirable.  Wounds  thus  cov- 
ered remain  perfectly  dry,  even  if 
left  alone  for  a  week  to  ten  days, 
and  epidermization  is  much  acceler- 
ated. In  osteoplastic  flaps  the  scars 
are  so  faint  they  are  scarcely  visible. 
Skin  grafts  may  be  left  untouched  for 
a  week  to  ten  days,  though  occasion- 
ally blood  and  serum  collect  beneath 
some  of  the  grafts.  In  granulating 
wounds,  healthy  granulations  are 
rapidly  covered  over  with  epithelium 
under  the  foil,  without  the  formation 
of  much  granulation  tissue.  They 
become  flatter.  The  silver  foil  ap- 
parently has  an  inhibitory  effect  upon 
the  growth  of  granulation  tissue. 
The  surface,  when  healed,  is  even 
with  the  surrounding  skin.  The  sil- 
ver foil  is  also  advised  in  skin 
sutures  beneath  plaster-of-Paris  casts. 
E.  Lexer  (Zentralbl.  f.  Chir.,  Bd.  xlii, 
S.  217,   1915). 

Disorders  of  the  Respiratory  Tract. 
— Acute  pharyngitis  may  be  aborted 
by  the  early  application  of  a  60-grain 
(2  Gm.)  to  the  ounce  (30  c.c.)  solu- 



tion.  In  laryngitis  the  parts  should 
be  cleansed  with  an  alkaline  solution, 
the  parts  anesthetized  with  a  solution 
of  cocaine,  and  by  the  aid  of  a  brush 
and  mirror  a  10-  or  20-  grain  (0.65 
or  1.3  Gm.)  to  the  ounce  (30  c.c.) 
solution  of  silver  nitrate  applied  to 
the  larynx. 

In  laryngeal  tuberculosis  a  spray 
of  silver-nitrate  solution  in  the 
strength  of  3^  to  2  grains  (0.03  to 
0.12  Gm.)  to  the  ounce  (30  c.c.)  may 
be  of  service.  Crocq  claims  that  sil- 
ver nitrate  is  a  valuable  remedy  in 
pulmonary  tuberculosis,  promoting 
appetite  and  digestion  and  diminish- 
ing cough,  expectoration,  and  night- 
sweats.  He  administers  from  %  to 
Ys  grain  (0.008  to  0.02  Gm.)  daily,  in 
divided  doses.  It  may,  with  advan- 
tage, be  given  in  a  %-grain  (0.01 
Gm.)  dose  combined  with  3  grains 
(0.2  Gm.)  of  Dover's  powder. 

In  pertussis  Ringer  advised  the  use 
of  a  spray  of  silver-nitrate  solution 
(>4  to  2  grains— 0.03  to  0.3  Gm.— to 
1  ounce — 30  c.c.)  to  relieve  the  vio- 
lence of  the  cough  and  give  the  pa- 
tient rest  at  night.  The  spray  should 
be  used  when  the  stomach  is  empty, 
as  it  may  bring  on  retching.  The 
nozzle  of  the  atomizer  should  be 
placed  well  within  the  mouth  to  pre- 
vent staining  of  the  skin. 

In  atrophic  rhinitis  and  ozena, 
Gleason  obtained  good  results  by 
painting  a  20  per  cent,  solution  of 
argyrol  over  the  afifected  area. 

Ophthalmic  Disorders. — ^^Silver  ni- 
trate is  found  useful  in  ophthalmolog- 
ical  practice  in  all  strengths  from  a 
1-grain  (0.06  Gm.)  solution  to  the 
solid  stick. 

In  simple  conjunctivitis,  where  the 
discharge  is  profuse,  a  2-  to  5-  grain 
(0.13  to  0.3  Gm.)  solution  is  of  value 

In  purulent,  including  gonococcal, 
ophthalmia,  when  the  discharge  is 
profuse,  the  lids  should  be  everted 
and  wiped  dry,  and  painted  with  a 
10-  to  15-  grain  (0.6  to  1  Gm.)  solu- 
tion of  silver  nitrate,  immediately 
neutralized  with  a  solution  of  com- 
mon salt.  This  should  be  done  once 

Protargol  is  more  satisfactory  than 
either  argyrol  or  silver  nitrate  for  the 
treatment  of  acute  mucopurulent  con- 
junctivitis due  to  the  Koch-Weeks 
bacillus.  Argyrol  is  better  than  sil- 
ver nitrate.  Protargol  is  perfectly 
safe  up  to  33  per  cent.  Its  applica- 
tion causes  much  less  pain  than  sil- 
ver nitrate,  but  more  than  argyrol. 
The  solution  was  freely  used  and  the 
excess  left  in  the  eye.  It  was  always 
applied  with  small  pellets  of  absorb- 
ent cotton.  Drops  for  home  use  were 
always  given — silver  nitrate  in  0.2 
per  cent,  strength,  or  argyrol  or 
protargol  in  5  per  cent,  solution. 
Butler  (Ophthalmoscope,  Jan.,  1907). 
Many  more  cases  of  conjunctival 
argyria  result  from  the  use  of  or- 
ganic silver  compounds,  such  as  pro- 
targol and  argyrol,  than  from  silver 
nitrate.  The  writer  protests  against 
the  almost  universal  use  of  such  com- 
pounds in  acute  and  chronic  catarrhal 
conjunctivitis.  For  these  conditions 
a  collyrium  containing  ^  grain  (0.03 
Gm.)  zinc  sulphate  and  10  to  12 
grains  (0.65  to  0.77  Gm.)  of  boric 
acid  to  the  ounce  (30  c.c.)  is  more 
surely  and  promptly  efficacious  than 
the  silver  compounds  mentioned.  S. 
Theobald  (Johns  Hopkins  Hosp. 
Bull,  Nov.,  1911). 

Granular    lids    and    trachoma    are 

benefited  by  silver  nitrate.  If  there 
is  slight  discharge  the  stick  should  be 
used;  if  there  is  copious  discharge, 
the  use  of  a  10-grain  (0.6  Gm.)  solu- 
tion, with  neutralization  of  excess, 
once  daily  will  be  followed  by 

In  blepharitis,  Hinshelwood  recom- 


mends  the  use  of  argyrol,  a  strong  upon  to  overcome  the  more  severe  in- 

solution  of  which  is  rubbed  into  the  fective  conjunctival  inflammations, 

lid     margins    after     each     has    been  Cutaneous  Disorders. — It  is  claimed 

cleaned  of  crusts  with  a  camel's-hair  that  pitting  in  smallpox  may  be  pre- 

brush   cut  short.     This   procedure  is  vented  by  puncturing  the  vesicles,  on 

applied    at    first     daily,    then    every  the  fourth  or  fifth  day,  with  a  needle 

second  or  third  day.  dipped  into  a  4  per  cent,  solution  of 

In  diphtheritic  conjunctivitis,  after  silver  nitrate.     Others  paint  the  skin 

the  absorption  of  the  membrane  and  with  a  1  or  2  per  cent,  solution,  and 

the  re-establishment  of  the  discharge,  claim  that  it  is  equally  effective.    The 

one  may  cautiously  use  silver-nitrate  mitigated  stick  has  also  been  used, 

solution  as  in  purulent  ophthalmia.  Silver   nitrate   is   also    used   to   de- 

Crede  initiated  the  use  of  a   1-  or  stroy    parasitic    fungi,    to    cause    ex- 

2-  per  cent,  solution,  1  drop  in  each  foliation   of   the   epidermis,   or   for   a 

eye,  in   the  eyes  of  all  newborn   in-  local  stimulant  effect.     As  a  caustic 

fants   to  prevent   the   occcurrence   of  it  is  inferior  to  several  other  agents. 

ophthalmia  neonatorum.     This  is,  by  It    has    been    found    useful    in    some 

many,     made    a     routine     procedure,  forms  of  eczema   (chronic  forms  and 

Where  all  possibility  of  infection  of  circumscribed  patches),  and  in  reliev- 

the  birth  canal  can  be  excluded,  flush-  ing  the  itching  of  prurigo  and  lichen. 

ing  out  with  a  saturated   boric   acid  Pruritus  ani  and  pruritus  vulvae  may 

solution  is  sufiicient.  be  benefited  by  a  4-  or  6-  grain  (0.25 

Silver  nitrate  cannot  be  used  safely  or  0.4   Gm.)    to   the   ounce    (30   c.c.) 

in  the  eye  in  a  solution  stronger  than  solution  painted  upon  the  parts  two 

3  per   cent.     A  2  per  cent,  solution,  to  four  times  daily, 

even  if  neither  neutralized  or  washed  The     use     of     silver     nitrate     has 

out,  never  causes  any  irritation.    Any  also    been     recommended    in     lupus, 

solution    stronger    than    3    per    cent.,  psoriasis,    erythema,    ringworm,    and 

unless  at  once  neutralized  with  salt  erysipelas. 

solution,   leaves   a   faint   film   of  de-  Venereal  Disorders. — In  the  treat- 

stroyed      epithelium,     especially     in  ment    of    buboes    good    results    have 

infants  (Butler).  been   reported    from    injections   of   a 

The  use  of  silver  should  be  inter-  2  per  cent,  solution  of  silver  nitrate 

dieted   where   corneal   ulceration   ex-  in  the  early  stage, 

ists,    and    when    continued    use   of    a  In     orchitis     and     epididymitis     a 

remedy    is    desired.      The    danger   of  strong  solution  of  the  nitrate  painted 

permanently  staining  the  tissues  must  over  the  scrotum,  in  the  early  stages, 

not  be  forgotten.  will  often  relieve  the  pain  and  reduce 

In  place  of  silver  nitrate,  protargol  the  swelling. 
(5  to  20  per  cent.)  and  argyrol  (5  to  Injections  of  silver-nitrate  solu- 
50  per  cent.)  are  often  used.  Their  tions  are  most  useful  in  the  later  sub- 
advantages  consist  essentially  of  less  acute  stages  of  gonococcal  urethritis, 
irritant  power  and  greater  ease  of  em-  in  the  strength  of  1  part  of  the  salt 
ployment,  but  their  antiseptic  power  in  500  to  3000  parts  of  water,  bc- 
is  decidedly  inferior.  Neither  (espe-  ginning  with  the  weaker  solution. 
cially   argyrol)    should   be    depended  Strong    solutions     used    early    have 



been  advised  for  the  purpose  of 
aborting  the  disease ;  such  use  is, 
however,  not  to  be  commended. 

Fifty-five  men,  suffering  from  gon- 
orrhea, were  treated  with  injections 
of  protargol,  beginning  with  y\  io  Yz 
per  cent.,  and  increasmg  m  stiength 
to  1  per  cent.  The  patients  waslicd 
the  urethra  out  with  warm  water  be- 
fore injecting  the  protargol.  The 
protargol  injections  were  kept  at  first 
for  ten  minutes,  and  later  up  to  thirty 
minutes.  Of  the  55  patients,  only  2 
showed  signs  of  irritation.  The  aver- 
age time  occupied  in  causing  the 
gonococci  to  disappear  finally  from 
the  discharge  w-as  16.3  days. 

Five  children  with  gonorrheal  vul- 
vovaginitis were  treated  with  2  per 
cent,  solutions  for  the  acute  stages 
and  5  per  cent,  for  the  subacute 
stages.  The  parts  were  cleaned  and 
the  solution  injected  into  the  vagina 
and  kept  there  for  ten  minutes,  the 
pelvis  being  raised.  None  of  the 
children  complained  of  irritation. 
Sitz  baths  were  employed  as  a  sup- 
plementary treatment.  It  took  on  an 
average  of  three  months  befoie  the 
last  cocci  were  removed  from  the 
secretion  of  the  vagina  and  cervix. 

Protargol  yielded  as  good  or  better 
results     in     female     gonorrhea     than 
other  means.     The    writer   employed 
it  in   solutions   of   from  5   to    10  per 
cent.,  and   met  with   no   irritating  ef- 
fect.     Irritant    effects    are    probably 
due   to    worthless   imitations   of   pro- 
targol, and  at  times  to  the  solutions 
not  being  made  up  freshly  with  cold 
water.     C.  Stern   (Deut.  med.   VVoch., 
Feb.  7,  1907). 
The  drug  is  also^  useful  in  1 :  500  to, 
1 :  5000   strength    in   prostatitis,   sem- 
inal vesiculitis    (after  massage),  and 
the   cystitis   of  enlarged  prostate,   or 
bladder  stone  or  tumor. 

Gynecological  Disorders. — In  ul- 
ceration of  the  cervix,  and  in  those 
cases  of  leucorrhea  in  which  the 
cervix  is  boggy  and  tender,  great 
benefit  may  follow  the  application  of 

the  solid  stick  within  the  cervix. 
This  procedure  is  frequently  followed 
by  headache  about  the  vertex,  but 
this  can  be  relieved  with  10-grain 
(0.6  Gm.)  doses  of  the  bromides. 
Silver-nitrate  solutions  were  used 
very  extensively  for  erosions  of  the 
cervix,  btit  other  remedies  have  sup- 
planted them.  Vomiting  of  preg- 
nancy can  sometimes  be  relieved  by 
brushing  the  cervix  over  with  a  60- 
grain  (4  Gm.)  solution  of  the  nitrate. 

Removal  of  Silver  Stains. — Silver 
stains  on  clothing  may  be  washed  off 
with  a  solution  containing  45  grains 
(3  Gm.)  of  potassium  cyanide,  5 
grains  (0.3  Gm.)  of  iodine,  and  1 
ounce  (30  c.c.)  of  water.  Another 
method  is  to  dissolve  15  grains  (1 
Gm.)  of  corrosive  sublimate  in  7 
ounces  (210  c.c.)  of  boiled  water,  and 
add  about  45  grains  (3  Gm.)  of  so- 
dium chloride  just  before  using;  the 
stained  material  is  to  be  placed  in  it 
for  about  five  minutes  and  then 
washed  two  or  three  times.  Hahn 
advises  the  use  of  a  solution  contain- 
ing 75  grains  (5  Gm.)  each  of  corro- 
sive sublimate  and  of  ammonium 
chloride  dissolved  in  10  drams  (40 
c.c.)  of  water. 

When  the  stains  are  older  they 
may  be  rubl:)ed  with  a  mixture  of 
iodine  and  ammonia,  and  the  part, 
still  wet,  then  washed  thoroughly. 
(When  dry,  it  is  highly  explosive.) 

Potassium  cyanide  in  solution  will 
generally  remove  stains  from  the 
fingers  or  skin.  The  part  should  be 
well  rinsed  immediately  afterward. 
Or,  the  skin  may  be  covered  with 
tincture  of  iodine  and  then  washed 
off  with  a  solution  of  sodium  thio- 
sulphate   (hyposulphite). 

L.  T.  DE  M.  Sajoits, 




SORY; DISEASES  OF.— The  nasal 
accessory  sinuses,  the  maxillary,  or 
antrum  of  Highmore,  the  frontal, 
ethmoidal  and  sphenoidal,  are  com- 
monly involved  in  various  disorders : 
acute  and  chronic  rhinitis,  the  vari- 
ous diseases  of  childhood,  and  also  in 
pneumonia,  influenza  and  typhoid 
fever,  through  extension  of  the  infec- 
tion  to  them.  Especially  is  this  apt 
to  be  the  case  when  septal  deviation, 
nasal  polypi,  turbinate  hypertrophy, 
or  any  other  condition  capable  of  in- 
terfering with  proper  drainage  of  the 
nasal  cavities  is  present.  These  con- 
ditions may  also  provoke  chronic  in- 
flammation of  the  sinuses,  due  to 
accumulation  in  them  of  secretions 
containing  pathogenic  bacteria.  It 
may  also  be  caused  by  chronic  ca- 
tarrhal disorders,  in  which  intumes- 
cence of  the  nasal  mucosa  is  more 
or  less  permanent,  and  characterized 
by  mucopurulent  discharge.  The 
source  of  infection  may  be  located  in 
the  mouth.  Not  only  may  carious 
teeth  awaken  suppuration  of  the  an- 
trum when,  as  in  the  case  of  certam 
bicuspids  and  molars,  this  sinus  is 
penetrated  by  the  roots  of  teeth,  but 
also  through  germs  such  as  the  end- 
ameba,  pneumococcus  and  other  or- 
ganisms concerned  with  pyorrhea 
alveolaris.  Tonsillar  streptococci  are 
also  thought  to  prove  pathogenic  in 
some  instances.  Syphilis,  tubercu- 
losis, carcinoma,  sarcoma  and  other 
destructive  processes  may  also  extend 
to,  or  occur  in,  either  of  the  sinuses. 
Their  bony  framework  may  be  in- 
volved in  fractures,  punctured  wounds 
and  other  traumatisms. 

The  pathological  changes  induced 
are  characteristic.  Although  the  mu- 
cosa covering  the  walls  of  the  various 

sinuses  is  hardly  one  twenty-fourth  of 
an  inch  thick,  inflammation  with  the 
accompanying  edema  may  cause  it  to 
swell  to  eight  or  nine  times  this 
thickness,  and  to  become  polyp-like. 
The  cavity  becomes  more  or  less  oc- 
cluded as  a  resonance  chamber,  while 
the  pressure  exerted  centrifugally  by 
the  swollen  mucosa  upon  its  walls 
may  cause  pain,  such  as  that  pro- 
duced in  the  frontal  sinus  in  the 
course  of  influenza,  in  the  antrum 
during  a  local  inflammation,  etc.  The 
first  mucoid  secretion  soon  becomes 
replaced  by  mucopus,  unless  arrested 
in  the  first  stage,  owing  to  invasion 
by  pyogenic  bacteria  and  phagocytes. 
While  this  may  occur  in  any  sinus, 
the  frontal  and  maxillary  sinus,  or 
antrum  of  Highmore,  are  the  seats  of 
predilection  for  a  purulent  process. 

Important  in  this  connection  is  the 
formation  of  fistulous  openings  where 
the  orifices  of  a  sinus  are  occluded 
sufficiently  by  the  swollen  mucosa  to 
prevent  the  discharge  of  pus.  These 
openings,  which  occur  through  the 
thinnest  and  weakest  portion  of  the 
walls  of  the  sinus,  may  entail  severe 
complications,  such  as  orbital  cellu- 
litis, infection  of  the  cranial  contents, 
meningitis,  periostitis  of  the  osseous, 
tissues  adjoining  the  sinuses,  etc. 
Disorders  of  the  nasal  accessory 
sinuses,  therefore,  may  prove  danger- 
ous to  life  if  neglected. 


DERS.— The  maxillary  sinus  may  be 
seat  of  acute  or  chronic  inflammation. 

Acute  Inflammation. — This  disor- 
der may  occur  as  an  extension  of 
an  acute  rhinitis  or  some  inflamma- 
tory   disorder   of   the   anterior   nares. 



through  the  antral  opening  below  the 
middle  turbinate,  the  invasion  of 
pus,  irritating  powders  or  fumes,  in- 
sects, foreign  bodies,  etc.,  or  occur  as 
one  of  the  manifestations  of  a  gen- 
eral infection  or  toxemia. 

The  main  symptom  is  a  neuralgic 
pain  referred  to  the  cheek  of  the  af- 
fected side.  It  presents  as  a  charac- 
teristic feature  that  of  being  most 
severe  in  the  region  of  the  malar 
bone.  If  the  nasal  disorder  be  such 
as  to  occlude,  by  swelling,  the  ostium 
maxillare,  the  pain  may  be  severe  and 
extend  to  the  orbital  region.  The  pain 
may  also  affect  the  upper  dental  arch, 
even  though  the  teeth  of  the  corre- 
sponding area  be  normal,  owing  to 
the  tension  in  the  antral  cavity. 

All  these  symptoms  become  ag- 
gravated where  the  antral  exudate 
becomes  purulent.  The  teeth  which 
bury  their  roots  in  the  lower  portion 
of  the  antrum,  and  adjoining  teeth, 
give  rise  to  severe  pain  on  being  per- 
cussed. While  a  diseased  tooth — 
either  the  second  bicuspid  or  first 
molar — in  most  instances  is  a  frequent 
cause  of  antral  sinusitis  and  abscess, 
the  determination  of  this  fact  should 
be  left  to  a  competent  dentist.  Sound 
teeth  have  often,  been  removed  by 
incompetent  or  careless  operators. 
'  The  antrum,  owing  to  its  size,  is 
the  most  prolific  source  of  discharge 
of  all  the  sinuses.  At  first  mucoid 
and  gelatinous,  it  eventually  assumes 
a  mucopurulent  character,  and  is 
voided  through  the  nasal  orifice  if 
the  latter  be  patent  and  into  the 
nose,  and  drawn  thence  into  the  naso- 
pharynx and  expectorated  or  swal- 
lowed, especially  if  the  nasal  passage 
of  the  corresponding  side  be  ob- 
structed, or  if  the  patient  is  in  the  re- 
cumbent position.    If  the  nasal  cavity 

is  relatively  ])atent,  the  discharge  is 
voided  anteriorly.  It  is  apt  to  have 
a  foul  odor  if  the  cause  of  the  antral 
purulent  process  be  due  to  diseased 
teeth.  When  the  discharge  is  pent 
up  in  the  cavity  through  blocking  of 
the  nasal  orifice  a  fistuluus  opening  is 
formed  unless  the  mucopus  be  arti- 
ficially removed  or  resolution  occur 
spontaneously.  The  pus  may  break 
through  the  nasal  wall,  forming  a 
fluctuating  tumor  in  the  middle 
meatus,  i.e.,  Under  the  middle  turbi- 
nate, or  through  the  lower  portion  of 
the  anterior  wall  of  the  sinus,  and 
escape  in  the  sulcus  between  the  gum 
and  the  cheek  above  the  first  or 
second  molar. 

Chronic  Inflammation,  or  Empy- 
ema.— This  condition  results  from 
the  acute  form  when  it  fails  to  dis- 
appear spontaneously  or  remain  un- 
treated. The  membrane  then  be- 
comes organized,  thickened,  irregular 
and  polypoid  in  character,  polypi 
sometimes  projecting  through  the  an- 
tral orifice  beneath  the  middle  turbi- 
nate. In  most  cases,  however,  this 
orifice  remains  patent,  and  gives  pas- 
sage to  a  free  discharge  which  is 
found  in  this  location,  i.e.,  the  middle 
meatus,  the  elimination  of  which,  an- 
teriorly or  posteriorly,  is  subject  to 
the  same  conditions  as  in  acute  sinu- 
sitis. Exacerbations  of  discharge  oc- 
cur along  with  temporary  catarrhal 
symptoms.  At  times  the  mucopus 
eliminated  is  very  fetid  and  imparts 
its  fetor  to  the  patient's  breath.  But 
little,  if  any,  pain  is  complained  of, 
and  general  phenomena,  fever,  etc., 
are  seldom  observed. 

Although  some  cases  may  undergo 
spontaneous  resolution,  the  majority 
persist  sluggishly  during  many  years, 
undergoing    periodical    exacerbations 



of  activity.  These  may  occur  after 
apparent  cure  through  appropriate 
measures,  so  that  in  all  cases  the 
prognosis  should  be  guarded. 

The  diagnosis  of  antral  inflamma- 
tion is  not  difficult  when  the  location 
of  the  pain,  the  presence  of  pus  in  the 
middle  meatus,  and  marked  sensitive- 
ness of  the  teeth  immediately  beneath 
the    antrum    can    be    discovered.      In 
most    cases,    however,    transillumina- 
tion— a    strong    electric    light    being 
placed  in  the  mouth— should  be  used, 
'showing    as    it    does    obstruction    to 
light   on   the    diseased    side    as    com- 
pared with  the  relative  free  illumina- 
tion on  the  normal  side.     It  affords, 
at     least,     corroborative     testimony. 
When  both  antra  are  diseased,  an  ex- 
ploratory  puncture   of  the   suspected 
antrum  beneath  the  inferior  turbinate, 
under    local    anesthesia,    may    be    re- 
sorted to,  but  only  under  strict  anti- 
septic precautions.     In  marked  cases 
empyema    may    be    recognized    after 
carefully    spraying   out   the   nose,   by 
causing  the  patient  to  bend  his  head 
over  to  one  side,  when  a  marked  ac- 
cumulation of  purulent  exudation  will 
appear  in  the  uppermost  nostril.    Per- 
cussing the  cheek  and  the  teeth  may 
elicit  suggestive  pain. 

The    writer    questions    the    efficacy 
of    transillumination    as    the    deciding 
factor  in  determining  antral  suppura- 
tion,    and     places     more    dependence 
upon    the    suction    syringe    for    diag- 
nostic   purposes.      The    specially    de- 
vised  needle   is   readily   inserted,   and 
nearly  a  syringeful  of  water  is  quickly 
injected    into    the    cavity    of    the    an- 
trum,  and   at   once   sucked   back   into 
the    syringe,    in    order    to    obtain    a 
specimen   of  the   antral  contents.     In 
a  number  of   cases  the  writer's   sus- 
picions   of    antral    suppuration    were 
negatived  by  excellent  transillumina- 
tion,  with   pupil   reflex,  whereas,   the 

use  of  the  syringe  revealed  the  pres- 
ence of  thick  pus  in  greater  or  less 
amount,  or  the  existence  of  plugs  of 
mucus  with  or  without  pus.  Wil- 
liams (Jour,  of  Laryn.,  Rhin.,  and 
OtoL,  Mar.,  1912). 

When    from    any   cause,   the   nasal 
opening  of  the   antrum  becomes  oc- 
cluded— through  swelling  of  the  nasal 
membrane,   polypi,    plug   of   purulent 
material,  diphtheritic  membrane,  etc. 
— all    the    symptoms,    especially    the 
pain   and    swelling,   become   progres- 
sively   worse.      The    pain    finally   be- 
comes intense,  while  the  swelling  in- 
cludes   bulging    of    all    neighboring 
parts,   the    cheek,    palate,    gums    and 
teeth,  eyeball.     Symptoms  of  pyemia, 
chills,  sweats,  and  high  fever  also  ap- 
pear.    Thinning  of  the  walls  of  the 
sinus  progresses,  however,  and  finally 
rupture    occurs    either    tlyough    the 
palate,  alveolar  process,  orbit  or  nasal 
cavity.     As  soon  as  the  pus  is  evacu- 
ated in  this  manner  all  the  symptoms 
disappear,    apart    from    those    of    the 
remainine    chronic    inflammation    de- 
scribed    above,    and    a    more    or    less 
permanent  fistula. 

In  an  examination  of  100  heads  in 
the  necropsy  room,  the  writer  found 
that   37  per   cent,    showed   some   evi- 
dence of  pathological  changes  in  the 
maxillary   antra.     Of  these  37   cases, 
11  were  examples  of  edema;  12  were 
examples  of  chronic  inflammation  or 
empyema;    1    was    an   example   of   an 
alveolar  or  dental   cyst,  and  13  were 
examples    of    retention    cyst.      With 
one   or  two   exceptions,   all    of   these 
cases    were   undiagnosed    during   life. 
The   presence   of    a   large   amount   of 
pus  in  10  out  of  12  of  these  cases  of 
empyema  may  have  played  an  active 
part  in  causing  the  death  of  the  pa- 
tients.    J.    P.    Tunis    (Laryngoscope, 
Oct.,  1910). 

TREATMENT,— In  all  the  phases 
of  antral  inflammation  careful  atten- 


tion  should  be  given  to  the  nasal  In  mild  or  incipient  cases  due  solely 
cavity.  Acute  cases  and  exacerba-  to  the  presence  of  an  inflammatory 
tions  of  activity  in  chronic  cases  may  disorder  in  the  cavities,  this  mild 
often  be  checked  if  seen  early  when  treatment,  if  persisted  in,  sufifices  to 
a  nasal  inflammatory  disorder  is  the  check  the  antral  trouble.  It  should 
cause,  by  thorough  cleansing  with  be  remembered  that  polypi,  hyper- 
warm  saline  solution,  used  freely  with  trophy  of  the  middle  and  inferior  tur- 
a  coarse  atomizer,  followed  by  the  binal,  a  foreign  body,  etc.,  may  prove 
local  application,  with  a'  pledget  of  to  be  the  exciting  cause,  and  that  ap- 
cotton  on  a  nasal  probe,  of  the  gly-  propriate  treatment  of  these  condi- 
cerite  of  iodotannin,  which  is  pre-  tions  is  necessary, 
pared  as  follows: —  The  teeth,  the  roots  of  which  pro- 

B  lodi    Sss  (2  Gm.).  ject  into  the  sinus  from  below,  being 

Acidi  tannici  ,Sss  (15  Gm).  occasionally  the  source  of  antral  in- 

^^^   Oss  (250  c.c).  flammation,  they  should  be  carefully 

M.    Filter  and  evaporate  to  Bij    (62  c.c.)  examined.      Mere    sensitiveness    un- 

and  add  i                        .          , 

„,       .  cler    percussion    does    not    warrant    a 

Glycerini  fjiv  (125  c.c.) .  i      ■        .  i     .     i                   i 

J'                             ..      ow  y    o  c.c.;.  conclusion  that  they  are  the  source  of 

This  solution  is  applied  freely  over  trouble,  since  inflammation  of  nasal 
the  nasal  mucosa,  and  particularly  origin  may  also  cause  neuralgia  in  the 
under  the  middle  turbinate,  the  area  upper  dental  arch.  Teeth  should  only 
forming  the  middle  meatus  into  which  be  drawn,  therefore,  after  an  X-ray 
the  orifice  of  the  antrum  opens.  If  the  bas  clearly  shown  them  to  be  the 
tissues  are  sw^ollen,  the  application  of  cause  of  the  antral  disorder.  Since 
the  above  should  be  preceded  by  a  the  recognition  of  the  fact  that  pyor- 
spray  of  4  per  cent,  solution  of  co-  ibea  alveolaris  is  present  in  most  per- 
caine  to  contract  it  and  anesthetize  it.  sons  after  the  thirtieth  year,  espe- 
This  treatment  should  be  carried  out  cially  in  view  of  the  resistance  of  the 
by  the  physician  daily.  The  patient  Endamcba  buccalis,  a  communication 
should  then  be  shown  how  to  use  between  the  mouth  and  the  antrum 
drops  into  the  nose  in  such  a  way  as  should  be  avoided  when  at  all  pos- 
to  cause  them  to  bathe  the  outer  wall,  sible.  It  is  probable,  in  fact,  that  the 
including  the  space  under  the  middle  persistence  of  empyema  treated  in 
turbinate,  i.e.,  by  bending  his  head  this  manner  and  necessitating  a  per- 
well  over  on  side  of  the  sinusitis.  He  manent  tube  or  plug  in  the  alveolar 
should  then  be  ordered  to  spray  his  perforation  is  due  to  constant  reinfec- 
nose  carefully  night  and  morning  with  tion  by  gingival  organisms.  When, 
saline  solution  to  cleanse  it,  then  to  therefore,  the  exciting  cause  is  clearly 
apply  5  or  6  drops  of  1 :  5000  solution  traced  to  a  tooth  and  it  becomes  nec- 
of  adrenalin  into  the  nostril  of  the  essary  to  extract  the  latter  to  irrigate 
afifected  side,  and  after  a  few  minutes  the  sinus,  it  is  best  to  pack  the  open- 
follow  this  up  with  a  spray  of  the  i^g  with  iodoform  gauze,  and  to  re- 
following  oily  solution: —  peat  the  irrigations  a  few  times.  If 
Camphor,  this  does  not  suffice  to  cure  the  antral 

Menthol    aa  gr.  j   (0.06  Gm.).  disorder — which   it  often   does  in   re- 

Benzoinol   l\]  (62  c.c).  cent  cases — it  is  preferable  to  allow 



the  alveolar  openingf  to  close  and  to 
create  an  opening  through  the  nasal 


The  alveolar  operation  should  never 
be  done  as  an  operation  of  choice, 
because  it  establishes  a  communica- 
tion between  the  mouth  and  a  sup- 
purating cavity,  and  requires  the  use 
of  a  tube  or  plug,  which  is  decidedly 
disadvantageous.  The  open  method 
of  doing  the  canine  fossa  operation 
is  likewise  to  be  condemned  on  much 
the  same  grounds.  When  simple 
irrigation  has  failed  or  is  not  prac- 
ticable, the  next  step  should  be  a 
large  opening  in  the  inferior  meatus, 
with  removal  of  a  portion  of  the 
inferior  turbinate.  If  this  method  is 
employed,  very  few  patients  will 
require  radical  operations.  Wells 
(Laryngoscope,   Dec,   1906). 

Having  encountered  a  case  of  fatal 
bleeding  in  entering  the  antrum  with 
a  sharp  trocar  through  the  inferior 
nasal  meatus,  as  well  as  occasional 
infections  of  the  pterygomaxillary 
fossa  from  excessive  momentum  of 
the  instrument  and  accidents  from 
entrance  of  the  point  of  the  trocar 
into  an  orbital  cell,  the  writer  deter- 
mined to  discard  the  sharp-pointed 
trocar  for  a  smooth-tipped  rasp  mod- 
elled after  those  used  by  Vacher  and 
by  Watson  Williams  for  penetrating 
into  the  frontal  sinuses.  An  opening 
large  enough  to  facilitate  irrigation 
and  avoid  premature  closure  is  thus 
made.  Luc  (Rev.  de  laryng.,  d'Otol. 
et  de  rhinol..  May  15,  1918). 

Although  the  ostium  maxillare  is 
most  easily  reached  and  penetrated, 
its  situation,  in  the  middle  meatus, 
i.e.,  under  the  middle  turbinate,  would 
cause  a  trocar  to  enter  the  antrum 
too  high  up  to  permit  of  effective 
drainage  through  the  nose.  It  is 
preferable,  therefore,  to  puncture  the 
thin  wall  of  the  antrum  which  faces 
tlie  area  beneath  the  inferior  turbi- 
nate. A  pledget  of  cotton  well-moist- 
ened,   a    10    per    cent,    solution    of 

cocaine  having  been  placed  in  this 
location  and  left  there  about  ten  min- 
utes, a  Coakley  or  Myles  trocar  and 
cannula,  sterilized  by  boiling,  is  in- 
troduced upward  and  outward  under 
the  inferior  turbinate  until  one  inch 
of  the  instrument  from  the  lower  edge 
of  the  nostril  has  entered  the  nose. 
The  trocar  is  then  pushed  in  through 
the  wall  into  the  antrum,  then  with- 
drawn, leaving  the  cannula  in  situ. 
Through  it  the  antrum  can  be 
drained,  then  washed  out  by  means 
of  syringe  with  saline  solution,  and 
again  drained  dry — a  measure  which 
often  suffices  in  recent  or  mild  acute 
cases  to  effect  a  cure. 

Efforts  must  be  chiefly  directed  to 
promoting  the  free  and  spontaneous 
discharge  of  pus  from  the  antrum  by 
way  of  the  natural  ostium,  by:  (a) 
directing  the  patient  to  lie  in  bed 
with  the  diseased  antrum  uppermost; 
(b)  the  application  of  cocaine  and 
adrenalin  solutions  to  the  regions 
around  the  middle  meatus — this  may 
be  done  every  four  or  six  hours;  (c) 
scarification  of  these  regions;  and 
(d)  inhalation  of  mentholized  steam. 
If  these  means  fail  the  antrum  should 
be  punctured  through  its  inner  wall 
in  the  inferior  meatus,  and  irrigated. 
Tilley  (Brit.  Med.  Jour.,  Aug.  22, 

It  should  be  borne  in  mind,  how- 
ever, that  the  anatomical  relations  of 
the  frontal  and  ethmoidal  cells  with 
the  antrum  render  the  latter  a  sort  of 
receptacle  for  discharges  from  the 
former.  When  all  these  structures 
are  diseased,  therefore,  drainage  of 
the  antrum  in  the  manner  described 
is  useful  in  several  ways. 

In  those  cases  in  which  the  entire 
chain  of  cells  is  diseased — the  an- 
trum, the  ethmoidal  cells,  the  frontal 
sinus,  and  in  many  cases  the  sphe- 
noidal sinus  also — Jansen  has  pro- 
posed  the    extensive   external   opera- 




tion  of  laying  open  the  entire  chain. 
This  operation  is  only  called  for  and 
only  warranted  in  extreme  cases  in 
which  the  cavities  are  the  seat  of 
myxomatous  or  other  growths.  In 
all  ordinary  cases  of  empyema  of  the 
antrum  and  ethmoidal  cells,  asso- 
ciated with  nothing  more  than  a  de- 
generated condition  of  the  mucous 
membrane  that  has  resulted  from  a 
prolonged  maceration  in  pus,  these 
external  operations  are,  in  the  opin- 
ion of  the  writer,  unnecessary,  for 
the  reason  that  diseased  conditions 
of  the  maxillary  sinuses,  and  also  of 
the  ethmoidal  cells,  which  are  com- 
monly associated  with  an  empyema, 
can  be  successfully  treated  by  the 
nasal  route.  J.  O.  Roe  (Annals  of 
Otol.,  Rhin.,  and  Laryn.,  June,  1909). 

It  is  sometimes  necessary,  owing  to 
the  necessity  of  keeping  the  artificial 
opening  patent  for  continued  drain- 
age and  local  treatment,  to  enlarge 
the  opening.  This  necessitates  re- 
moval of  the  lower  anterior  portion 
of  the  inferior  turbinate.  Wells's  op- 
eration is  much  used  for  this  purpose. 
In  this  procedure  the  anterior  half  of 
the  inferior  turbinate  is  first  removed 
under  local  anesthesia  with  a  10  per 
cent,  solution  of  cocaine  and  ischemia 
with  1 :  5000  solution  of  adrenalin  by 
means  of  serrated  scissors  and  the 
snare.  An  opening  is  then  made  with 
a  trocar,  as  explained  above,  but 
lower  down  and  close  to  the  floor  of 
the  nose.  This  opening  is  then  en- 
larged by  means  of  a  rasp,  used  in 
such  a  way  as  to  extend  the  opening 
anteriorly,  following  the  line  of  the 
nasal  floor  until  the  junction  of  the 
nasoantral  with  the  facial  wall  of  the 
antrum  is  reached. 

Skillern's  operation  obviates  the 
necessity  of  resecting  a  portion  of  the 
inferior  turbinate.  It  is  performed 
as  follows :  After  cleansing  the  nasal 
cavities,  anesthesia  is  secured  by  the 

application  f)f  a  20  per  cent,  solution 
of  cocaine  and  l)y  injections  of  novo- 
caine  and  adrenalin.  A  s])indle-shaped 
piece  of  mucous  meml)rane  is  re- 
moved in  front  of  the  inferior  tur- 
l)inate  by  two  incisions  extending 
through  all  tlie  tissues  to  the  bone, 
and  the  crista  pyriformis  is  exposed. 
With  a  chisel,  forceps  and  an  electric 
trephine  the  antrum  is  then  opened, 
flushed  out,  inspected,  curetted,  and 
packed  loosely  with  iodoform  gauze. 
The  gauze  is  removed  in  forty-eight 
to  seventy-two  hours  and  replaced 
every  second  day  for  two  weeks. 
This  operation  enables  the  operator 
to  inspect  directly  the  sinus  and  to 
follow  dc  visu  local  applications  to 
any  part  of  the  diseased  area,  includ- 
ing some  that  are  usually  resistant 
to  treatment. 

In  acute  maxillary  sinusitis  one 
should  irrigate  the  cavity  as  sug- 
gested for  empyema;  this  failing,  it 
may  be  necessary  to  make  a  wide 
artificial  opening  in  the  lower  part 
of  the  nasoantral  wall  for  ventila- 
tion. In  chronic  maxillary  sinusitis 
one  should  make  a  wide  artificial 
opening  in  the  nasoantral  wall;  this 
failing,  one  should  expose  the  sinus 
through  the  facial  wall,  and  curette 
the  interior.  Wells  (Med.  Rec,  Oct. 
29,   1910). 

We  have  seen  that  inflammation  of 
the  mucosa  of  sinuses  causes  it  to 
thicken  greatly  and  to  form  polypoid 
projections.  In  the  presence  of  pus 
this  thickened  mucosa  becomes  a 
soggy  mass  which  requires  the  con- 
servative use  of  the  curette — not  the 
vigorous  curetting  which  the  late 
John  O.  Roe  has  very  properly  con- 
demned— the  snare  for  polypoid 
masses,  and  the  application  of  reme- 
dies to  all  parts  of  the  diseased  cav- 
ity. This  can  only  be  done  by  means 
of    an    operation    which    enables    the 


operator  to   reach    the   sinus    through  procedure    Ly    his    experience    in    op- 

the   mouth    and    nose.      Such    a    pro-  ^''^ting   by   the   Luc-Caldwell   method, 

,  ,  .1        i->    u       11  T  when   he    frequently    found    a    mass    of 

cedure,   known   as    the    Caldwell-JLuc  ,    .       ^.  •     ,,      n  r  ,u 

granulation    tissue    in    the   floor   of   the 

operation,  is  begun  in  the  mouth  l)y  ^^trum  which  often  led  to  an  abscess 

means  of  an  incision  in  the  sulcus  be-  about    the    apex    of    a    tooth.     A.    R. 

tween    the    gum    and    lip    above    the  Solenberger     (Colo.     Med.,     xii,     269, 

bicuspid  and  first  molar.    The  perios-  1915). 

teum  being  detached  up  to  the  infra-  TUMORS  OF  THE  MAXILLARY 
orbital    canal,    an    opening   is    drilled  SINUS,  OR  ANTRUM. 

into   the   antrum    as   starting   for  re-  Polypi. — The     tumors     most     fre- 

moval,  by  means  of  rongeur  forceps  quently    found    in    the    antrum    are 

and  chisel,  of  the  greater  portion  of  polypi,  which,  as  stated  above,  often 

the  anterior  wall  of  the  sinus,  forming  occur  in  cases  of  empyema  of  long- 

a  gap  through  which  the  index  finger  standing.     They  may  either  develop 

may  easily  be  introduced.     Through  in  the  antrum  itself  or  project  out  of 

the   oroantral    opening   thus   made   a  the  antrum  into  the  nose  and  develop 

disk   of  bone   about   one-half  inch   in  under  the  middle  turl)inate. 
diameter  is  removed  from  the  nasal  Cysts. — These    are    of    two    kinds, 

wall,    including   the    anterior   half   of  The  one,  developed  from  the  mucosa 

the  inferior  turbinate.  of  the  antrum,  gives  rise   to  period- 

Besides  permitting  any  curetting  or  ical  discharges  of  a.  watery,  odorless 

snaring  that  may  be  necessary,   this  fluid,  and,  when  sufficiently  large,  to 

operation  affords  a  free  field  for  local  deformity  and'  bulging  of  the  affected 

treatment.       Irrigations    with    saline  side. 

solution,  followed  by  insufflations  of  The  second  variety  arises  from  an 

iodoform    over   all    parts   of   diseased  alveolus,  and  is  due  to  cystic  degen- 

surface,   a-nd   packing   with   iodoform  eration  of  the  peridental  membrane. 

gauze  daily  for  ,a  week  or  ten  days,  It  causes  erosion  of  the  antral  wall, 

will    usually    deal    effectively    with   a  penetrates  the  antrum  by  pushing  its 

case  of  empyema.    The  oroantral  open-  mucosa  before  it,  then  grows  rapidly, 

ing  may  be  closed  by   sutures   after  soon   filling  the   cavity,   and   causing 

free  drainage  and  the  use  of  the  cu-  deformity  of  the  face  and  palate  on 

rette  or  snare,  and  the  medical  treat-  the  corresponding  side.     A  character- 

ment   carried    on    through   the    nasal  istic  crackling  sensation  is  elicited  by 

opening.     At  times  stimulation  of  the  compressing    its    outer    wall.       If    it 

antral   membrane    is    necessary;    this  ruptures   it   yields   a  greenish,   thick, 

may  be  done  by  using  a  spray  of  25  odorless   fluid,   containing,  as   a  rule, 

per  cent,  solution  of  argyrol.     Irritant  cholesterin  crystals.      Unlike  the  other 

antiseptics  and  astringents  are  more  variety,  there  is  no  discharge  in  the 

harmful     than     beneficial     in     antral  nasal  cavity,  unless  it  ruj^tures,  when, 

diseases.  becoming    infected,    it    simulates    an 

Removal    of   a   tooth,   unless   it   can  empyema,  giving-  off  a  fetid  discharge, 
be    demonstrated    to    be    the^  offending  Osteoma'!— In    this    form    of   tumor. 

member,    is   bad    practice.      The   author  ^  i  t  i        i 

,        ,  ....  svmptoms   are   only   awakened   when 

advocates    an    examination    through    a         -       ' 

sufficiently    large    opening    in    tlic    an-  the   neoplasm   has  grown   sufficiently 

terior  wall.    He  was  led  to  adopt  this  to  compress  the  uasal  wall,  and  thus 



gradually  decrease  the  lumen  of  the 
nasal  passage  of  the  correspondintj 
side.  No  pain  is  experienced  until  a 
large  size  is  attained,  and  no  dis- 
charge of  an  abnormal  character  is 
complained  of.  An  exploratory  needle 
or  trocar  thrust  into  the  tumor  is  ar- 
rested as  soon  as  the  mucosa  is  pene- 
trated, and  transillumination  shows 
complete  darkness  as  compared  with 
the  other  side. 

Malignant  Tumors. — Sarcoma  and 
osteosarcoma  are  the  growths  most 
commonly  observed  in  the  antrum. 
Cases  of  psamnio-  sarcoma,  epithelioma, 
perithelioma  (Sakai)  and  endothelioma 
have  been  reported.  These  tumors, 
particularly  sarcoma,  grow  with  rela- 
tive rapidity  and  usually  cause  lan- 
cinating pain  and  considerable  swell- 
ing. After  filling  the  antrum,  they 
penetrate  into  the  nasal  or  naso- 
pharyngeal cavity,  rapidly  decreasing 
their  lumen  and  giving  rise  to  a  mu- 
copurulent discharge  often  streaked 
with  blood  and  detritus,  and  giving 
off  a  foul  odor.  The  glands  behind 
the  angle  of  the  jaws  are  enlarged 
soon  after  the  nasal  cavities  are 

Unique  case,  as  a  careful  search  of 
medical  literature  revealed  none  like 
it,  of  a  calculus  made  up  almost 
entirely  of  a  calcium  phosphate  and 
found  in  the  course  of  an  operation 
for  a  squamous-celled  epithelioma 
involving  the  antrum  of  Highmore. 
N.  H.  Carson  (Interstate  Med.  Jour., 
Mar.,  1913). 

TREATMENT.— The  removal  of 
polypi  from  the  antrum  requires,  as 
previously  stated,  sufficient  room  to 
render  the  use  of  the  curette  or  snare 
possible.  For  this  purpose  the  Cald- 
well-Luc  operation  affords  the  re- 
quired room.  This  applies  also  to  the 
removal  of  ordinary  cysts.    As  regards 

the  cysts  of  dental  origin  an  injection 
of  a  2  per  cent,  solution  of  phenic  acid 
into  the  cyst,  through  an  incision 
above  the  diseased  tooth  if  necessary, 
causes  shrinking  and  disappearance. 
If  the  growth  cannot  be  reached,  the 
Caldwell-Luc  buccal  opening  should 
be  practised,  and  the  cyst  removed, 
including  the  offending  tooth,  if 

Osteomata  can  only  be  removed  sat- 
isfactorily by  dissecting  up  the  facial 
tissues  from  the  antral  wall  and  by 
means  of  chisel  and  gouge  insure 
complete  excision  of  the  growth. 
This  operation,  which  should,  of 
course,  be  done  under  general  anes- 
thesia, is  but  rarely  followed  by 
recurrence.  In  malignant  growths  re- 
moval of  the  affected  superior  maxilla 
alone  affords  any  hope  of  recovery. 


DERS.— The  frontal  sinus  may  be 
the  seat  of  acute  and  of  chronic 

Acute  Inflammation. — In  this  con- 
dition, especially  when  suppuration  is 
present,  there  is  more  or  less  severe 
pain  between  and  above  the  eyebrows, 
which  presents  the  characteristic  of 
being  increased  by  leaning  forward 
and  by  coughing  and  of  being  so  ag- 
gravated on  blowing  the  nose  that  the 
patient  is  apt  to  avoid  emptying  the 
nasal  cavity  properly.  Percussion 
over  the  sinus  also  causes  pain ;  this 
is  likewise  the  case  when  pressure  is 
exerted  under  the  frontal  sinus,  i.e., 
on  the  orbital  plate  below  the  edge 
of  the  orbit  under  the  supraorbital 
foramen.  The  whole  superciliary  re- 
gion, especially  over  the  course  of  the 
supraorbital  nerves,  is  hyperesthetic. 
In  mild  cases  a  sensation  of  fullness 



and  weight  in  the  frontal  region  is 
alone  experienced.  The  discharge,  at 
first  serous,  may  become  bright  yellow 
and  purulent,  and  pass  down  into 
the  nasal  cavity  between  the  middle 
turbinate  and  the  outer  wall  of  the 
cavity,  but  if  the  orifice,  the  infun- 
dibulum,  be  obstructed,  the  sinus  is 
distended,  and  a  fistulous  opening 
may  form,  or  the  abscess  may  break 
into  and  invade  the  neighboring  an- 
terior ethmoidal  cells. 

Chronic  inflammation  of  the  frontal 
sinus  may  occur  as  a  result  of  acute 
inflammation  of  the  sinus,  or,  through 
extension,  a  chronic  ethmoiditis,  in 
which  the  anterior  ethmoidal  cells  are 
ruptured  through  distention  and  allow 
their  purulent  contents  to  penetrate 
into  the  frontal  sinus.  An  antral  em- 
pyema may  also  act  as  primary  cause. 
The  antral  mucosa  undergoes  poly- 
poid thickening,  and  sometimes  be- 
comes the  source  of  polypi  which 
project  into  the  nasal  cavity  and 
cause  considerable  annoyance.  In 
most  cases  but  little  pain  is  com- 
plained of,  a  sensation  of  fullness  or 
pressure  above  the  brow,  and  some 
tenderness  over  the  latter,  being  usu- 
ally experienced.  Swelling  or  bulg- 
ing over  the  frontal  sinus  may  also 
occur.  There  is,  in  most  cases,  con- 
.  siderable  discharge  which  may  be 
voided  anteriorly  or  posteriorly,  the 
patient  complaining  that  he  is  suffer- 
ing from  "nasal  catarrh."  Periodical 
discharges  of  mucoserous  or  muco- 
purulent fluid  may  afford  considerable 

Pent  up,  the  discharge  may  cause 
rupture  of  the  sinus  and  pass  into  the 
orbit,  the  nasal  cavity,  the  dura 
mater,  causing  meningitis ;  or  the 
lymphatics  may   serve  as  carriers  of 

pathogenic  bacteria  or  purulent  ma- 
terials to  the  meninges.  Edema  and 
redness  of  the  upper  eyelid  is  usually 
present.  Fistulous  openings  may  also 
form  anteriorly,  i.e.,  through  the  an- 
terior wall  of  the  sinus,  opening  above 
the  inner  canthus.  The  pain,  when  the 
suppuration  is  confined  in  the  latter, 
is  severe  and  constant,  and  often  as- 
sumes a  neuralgic  or  boring  charac- 
ter. Or,  persistent  headache  with 
insomnia  may  occur.  The  frontal  re- 
gion becomes  markedly  bulged,  and 
in  extreme  cases  one  or  both  eyeballs 
may  be  displaced,  causing  diplopia. 
Even  amaurosis  has  been  caused 
through  persistent  pressure  upon  the 
eyeball.  Systemic  phenomena,  sug- 
gesting pyemia  chills,  sweats,  fever, 
etc.,  are  often  observed  in  severe 
cases.  Persistent  pressure  may  so 
reduce  the  thickness  of  the  anterior 
walls  as  to  make  it  possible  some- 
times to  obtain  fluctuation  and  crack- 
ling. Unless  the  pent-up  discharge 
be  removed  surgically,  rupture  may 
occur  and  awaken  the  dangerous  com- 
plications recited  above. 

The  presence  of  a  frontal  abscess 
is  not  definitely  shown  by  trans- 
illumination. An  X-ray  photograph 
affords  a  clear  idea  of  the  topography 
of  the  sinus,  the  diseased  side  appear- 
ing relatively  dark.  If  the  same  area 
also  appears  dark  under  transillumi- 
nation, the  diagnosis  of  local  disease 
is  correspondingly  strong.  This  is 
further  strengthened  if,  on  examining 
the  nasal  cavity,  pus  or  polypi  are 
found  beneath  the  middle  turbinate 
into  which  the  infundibulum,  the 
elongated  outlet  of  the  frontal  sinus, 

TREATMENT.  — An  important 
feature  of  acute  frontal  sinusitis  is 
that  it  is  apt  to  develop  in  conjunc- 



tion  with  the  acute  rhinitis  attending 
various  febrile  disorders.  In  influ- 
enza, for  instance,  the  pain  aljout  the 
brow  is  due  to  this  cause.  The  local 
process  is  simply  that  of  occlusion  of 
the  infundibulum,  through  swelling 
of  its  mucosa.  The  escape  of  the 
mucus  to  the  nasal  cavity  being  pre- 
vented, distention  of  the  sinus  and 
swelling  of  its  mucosa  follow,  giving 
rise  to  the  painful  sensation.  The 
aim  should  be,  therefore,  to  free  the 
sinus  by  opening  it.  This  may  be 
done  with  a  spray  of  warm  saline 
solution  directed  upward  under  the 
middle  turbinal.  A  2  per  cent,  solu- 
tion of  cocaine,  containing  2  drams  (8 
c.c.)  of  the  1 :  1000  solution  of  adrena- 
lin to  the  ounce  (30  c.c.)  is  then 
sprayed  in  the  same  region,  the  pa- 
tient leaning  fonvard  while  using  the 
spray  in  order  to  cause  the  fluid  to 
flow  into  the  infundibulum.  After  a 
few  minutes,  considerable  relief  will 
be  experienced,  owing  to  contraction 
of  the  tissues  around  the  infundib- 
ulum, and  a  flow  of  mucus  will  soon 
follow.  Repeated  every  two  hours, 
this  procedure  will  prevent  suffering, 
unless  polypi  or  hypertrophies  pre- 
vent access  of  the  remedial  fluid  to 
the  frontal  passage. 

In  a  number  of  acute  cases  marked 
relief  was  obtained — because  of  the 
free  rhinorrhea  set  up — from  the  in- 
tranasal use  of  the  following  solu- 
tion: Mercuric  iodide,  1  Gm.  (15 
grains);  potassium  iodide,  4  Gm.  (1 
dram),  and  water,  100  c.c.  (iVs 
ounces).  D.  Macfarlan  (Jour.  Amer. 
Med.  Assoc,  Jan.  3,  1914). 

The  patient  should  be  kept  at  rest 
and  placed  on  a  light  diet,  avoiding 
stimulants,  coffee,  etc..  to  keep  the 
blood-pressure  within  its  normal 
limits.  Drugs,  such  as  opium,  bella- 
donna, etc.,  which  tend  to  cause  dry- 

ness of  the  mucous  membranes, 
should  be  avoided.  Saline  purgatives 
should  be  used  if  ihc  bowels  are  not 
free.  The  biniodide  of  mercury  in 
^20-grain  (0.003  Gm.)  doses  three 
times  daily  shortens  the  purulent 
process  by  enhancing  the  antitoxic 
.'uid  bactericidal  properties  of  the 
blood.  Hexamethylenamine,  4  grains 
(0.26  Gm. )  three  times  daily,  has 
been   recommended. 

The  same  local  treatment  some- 
times proves  useful  in  chronic  cases, 
when  used  four  times  daily,  the 
fourth  time  on  retiring,  giving  also 
the  biniodide  of  mercury.  If  it  fails, 
the  frontal  sinus  cannula  should  he 
introduced  into  the  sinus,  and  the 
frontal  sinus  washed  out  daily  with 
saline  solution,  the  patient  being 
taught  to  use  the  cannula  and  to 
wash  out  the  sinus  also  on  retiring. 
In  most  cases  the  cannula  is  easily 
introduced  by  passing  its  curved  tip 
upward  under  the  anterior  end  of  the 
middle  turbinate.  When  this  does 
not  suffice  to  insure  proper  drainage 
and  restore  the  sinus  to  its  normal 
condition,  removal  of  anterior  portion 
of  the  middle  turbinate  with  cutting 
forceps  is  indicated.  This  provides 
free  access  to  the  sinus  for  local  treat- 
ment by  injection  of  20  to  30  minims 
(1.25  to  1.8  c.c.)  of  a  10  per  cent, 
solution  of  argyrol  after  careful  wash- 
ing with  the  warm  saline  solution. 

When  these  less  radical  methods 
prove  insufficient  for  proper  drainage, 
opening  of  the  sinus  through  its  an- 
terior or  inferior  wall  becomes  neces- 
sary. When  this  is  done,  enough  of 
the  wall  must  be  removed  to  permit 
a  thorough  examination  of  the  cav- 
ity and  enlargement  of  the  naso- 
frontal duct  to  an  extent  sufficient 
for  free   drainage   into   the   nose.      If 



operation  is  delayed  too  long,  the 
continued  pressure  may  cause  rup- 
ture through  the  floor  into  the  orbit 
or  through  the  posterior  wall  of  the 
sinus  into  the  brain-cavity,  with  con- 
sequent purulent  meningitis  or  brain 

The  surgical  treatment  of  frontp- 
ethmoidal  sinusitis  has  progressed 
through  many  ch.nges.  To  cure 
frontal  sinusitis  and  prevent  its  re- 
currence it  is  necessary  to  eradicate 
the  cavity.  The  ethmoid  is  approached 
by  the  endonasal  route  so  that  when 
the  frontal  sinus  is  opened  all  that 
remains  to  be  done  is  to  enlarge  the 
nasofrontal  canal  at  the  level  of  the 
infundibular  region  for  free  drainage. 
The  modification  of  the  Ogsten-Luc 
operation  is  less  mutilating  and  fur- 
nishes excellent  drainage.  A  rather 
large  bony  opening  is  made  at  the 
level  of  the  frontal  boss  in  order  that 
the  whole  frontal  cavity  may  be  in- 
spected and  curetted  completely.  E. 
J.  Moure  (Laryng.,  xxxi,  479,  1921). 

Such  operations  should  be  per- 
formed only  by  a  highly  trained 
specialist,  as  otherwise  they  are 
fraught  with  danger. 

The  indications  for  the  external 
operation  of  the  frontal  sinus  may 
be  divided  into  absolute  and  relative. 
Absolute  indications  are:  (1)  Where 
the  disease  has  made  such  progress 
as  to  seriously  threaten  some  neigh- 
boring organ,  and  even  life  itself  is 
threatened,  or  there  are  actual  cere- 
bral and  orbital  complications.  (2) 
When  the  subjective  symptoms  are 
severe  enough  to  interfere  with  the 
business  pursuits  of  the  patient.  (3) 
When  severe  exacerbations  occur. 
(4)  In  abscess  or  fistula  formation. 
Relative  indications  are:  (1)  When 
the  headache  continues  with  no  ap- 
parent change  in  the  amount  or  con- 
sistency of  the  secretion.  (2)  When 
despite  frequent  irrigations  the  pus 
continues  fetid,  even  though  dimin- 
ishing slightly  in  amount.  (3)  When 
the  X-ray  shows  a   large  sinus  with 

many  ramifications  and  the  disease 
does  not  appear  to  yield  satisfactorily 
to  internal  treatments. 

As  to  the  type  of  operation,  this 
is  often  determined  by  the  patholog- 
ical change  present  or  the  anatom- 
ical configuration  of  the  sinus.  Other 
things  being  equal,  the  writer  per- 
forms his  modification  of  the  Jansen 
operation,  in  which  he  can  spare  the 
anterior  wall,  but  obtain  the  requisite 
space.  This  is  done  by  resecting  the 
superior  internal  portion  of  the  mar- 
gin of  the  orbit  and  the  floor  of  the 
sinus,  thus  exposing  the  entire  lower 
portion  or  funnel  of  the  frontal  sinus. 
After  this  has  been  done  the  usual 
procedures  are  followed,  i.e.,  removal 
of  diseased  mucosa,  the  ethmoid  cells, 
and,  if  necessary,  the  sphenoid  is 
opened.  The  communication  with 
^the  nose  may  be  enlarged  to  any 
desired  size  by  merely  removing  the 
orbital  plate  piecemeal  with  the  bone 
forceps.  The  wound  is  closed  and 
dressed  in  the  usual  manner.  R.  H. 
Skillern  (Laryngoscope,  xxv,  212, 

The  writer  believes  that  the  exter- 
nal (Killian)  operation  on  the  frontal 
sinus  has  not  fulfilled  the  brilliant 
hopes  that  were  raised  at  the  time 
of  its  introduction,  and  that  the  ear- 
lier successes  reported  have  been 
discounted  by  instances  of  septic 
osteomyelitis,  an  almost  universally 
fatal  complication,  even  in  the  hands 
of  skillful  operators.  In  many  cases 
very  grave  deformity  has  resulted, 
and,  in  addition,  the  operation  often 
fails  to  give  the  relief  sought. 

Intranasal  methods  for  obtaining 
drainage  and  space  for  lavage  by  the 
removal  of  the  anterior  end  of  the 
middle  turbinate  have  long  been 
practised  and  are  of  value,  but  are 
often,  also,  insufficient  to  effect  a 
cure.  To  Ingals  is  due  the  credit  of 
introducing  the  method  of  following 
up  the  frontonasal  duct  and  entering 
the  sinus  through  the  normal  ostium. 
All  subsequent  intranasal  methods 
are  developments  of  the  Ingals  op- 
eration. The  author  believes  most  of 
these  to  be  dangerous,  and  advances 



his  own  operation  as  being  compara- 
tively safe.  He  begins  lielow  and  an- 
terior to  the  middle  turbinate  and 
continues  upward  to  the  frontal 
sinus,  "without  destroying  any  part 
of  the  vertical  plate  of  the  ethmoid," 
a  point  he  thinks  of  much  impor- 
tancCj  since  he  says  it  does  not  in- 
volve fracturing  through  the  vertical 
plate  in  close  proximity  to  the  crib- 
riform plate  and  laying  open  venules 
and  lymphatics  in  this  dangerous 
area  to  infection.  The  writer's  op- 
eration may  be  done  with  cocaine, 
but  he  much  prefers  general  anesthe- 
sia. His  technique  is  simply  to  cut 
through  the  most  anterior  attach- 
ment of  the  middle  turbinate  with  a 
conchotome  and  continue  biting  up- 
ward through  the  anterior  cells  to 
the  crista  nasalis.  In  the  same  man- 
ner the  cells  lying  behind  the  duct 
are  then  removed  to  any  necessary 
extent.  Sounds  are  passed  into  the 
sinus  and  all  projecting  edges  re- 
moved. Often  this  will  suffice,  but 
if  enough  room  has  not  been  secured 
by  these  measures,  the  nasal  crest 
may  be  rasped  away,  but  it  is  much 
preferable  to  use  a  guarded  burr  for 
this  purpose.  The  advantage  claimed 
for  the  burr  is  that  the  mucous  mem- 
brane of  the  posterior  wall  is  left 
intact  and  the  bone  only  laid  bare 

He  advocates  the  use  of  from  30 
to  50  c.c.  of  polyvalent  antistrepto- 
coccus  serum  immediately  before  the 
operation,  followed  by  the  adminis- 
tration of  sensitized  vaccines.  Sounds 
should  also  be  passed  at  regular  in- 
tervals after  the  operation  to  insure 
the  permanency  of  the  opening  made. 

Over  one  hundred  frontal  sinuses 
have  been  treated  in  this  way  by  the 
author,  who  claims  that  many  have 
been  cured  and  nearly  all  relieved. 
In  a  few  instances  he  was  unable  to 
reach  the  sinus  pernasally.  P.  Wat- 
son-Williams (Surg.,  Gynec.  and  Ob- 
stet.,  from  Lancet,  July  15,  1915). 

As  stated  by  Shurly  some  years 
ago,  the  surgery  of  the  frontal  sinus 
will    become    more    conservative    as 

our  knowledge  grows.  The  relief 
should  come,  not  through  surgery 
alone,  but  from  prophylaxis  and  the 
successful  abortion  of  the  common 
colds.  An  important  feature  of  these 
cases  is  tlie  careful  treatment  of 
chronic  rhinitis  in  any  of  its  forms 
(see  Nose,  Diseases  of,  in  the  sev- 
enth volume).  A  change  to  a  semi- 
tropical  climate,  such  as  that  of 
I'lorida  or  Southern  California,  pref- 
erably near  the  seashore,  sometimes 
proves  curative. 



Mucocele. — Mucoceles  are  but  re- 
tention cysts  formed  by  closure  of 
the  infundibulum  and  the  accumula- 
tion of  the  exudate  within  the  sinus. 
This  gives  rise  to  a  feeling  of  disten- 
tion and  neuralgic  pain  in  the  supra- 
orbital region,  which  is  itself  exceed- 
ingly  sensitive  to  palpation.  In  some 
instances  there  is  formed  a  polyp- 
like tumor  of  the  swollen  mucosa 
which  is  visible  under  rhinoscopic 
examination  if  a  very  small  mirror  be 
used,  and  sufficient  often  to  form  a 
myxoma-like  tumor  under  the  middle 
turbinate.  In  others,  the  pressure  is 
also  exerted  anteriorly  or  laterally 
and  by  eroding  the  orbital  wall 
causes  displacement  of  the  eyeball. 

Case  of  an  unusually  large  muco- 
cele of  the  frontal  and  ethmoidal 
cells.  The  patient,  a  woman  69  years 
of  age,  was  first  examined  November 
25,  1914,  for  a  supposed  growth  of 
the  left  orbit.  There  were  two  lumps 
the  size  of  beans  just  below  the 
brow,  which  coalesced  and  formed  a 
marked  prominence,  displacing  the 
eye  outward  and  downward.  There 
was  no  pain  or  evidence  of  inflam- 
mation, nor  any  appreciable  derange- 
ment of  vision.  She  gave  a  history 
of   having   had   nasal   catarrh    several 



years  before,  but  had  not  been  trou- 
bled since.  Uncorrected  vision  was 
5/7.5  in  the  right,  5/9  in  the  left.  The 
fields  of  vision  were  normal.  The 
proptosis  of  the  left  eye  was  about 
1.5   cm.  in   advance  of  the  right. 

The  periocular  swelling  eventually 
reached  the  size  of  a  hen's  egg  and 
was  systic  to  the  touch.  The  rhino- 
logical  examination  showed  a  large 
cystic  mass  that  had  apparently  de- 
stroyed the  orbital  wall  of  the  frontal 
sinus.  The  left  nasal  fossa  was  free, 
although  the  lateral  wall  seemed 
more  prominent  than  usual  in  the 
agger  nasi  region.  Transillumination 
of  the  antrum  was  negative.  The 
X-ray  report  was  that  the  supra-or- 
bital ridge  was  completely  absorbed 
and  the  sinus  enlarged  upward  on 
the  frontal  bone. 

An    external    operation    was    per- 
formed with  the  incision  through  the 
brow  and  the  sac  exposed,  the  walls 
of  which  were  found  to  be  composed 
of   thickened  periosteum,   which   was 
filled  with  the  frontal  sinus  contents. 
The    bone    of    the    anterior   wall    and 
floor  of  the  sinus  had  entirely  eroded 
away,    and    the    ethmoid    cells    were 
exposed  on  the  removal  of  this  sac. 
These  were  partially  exenterated  and 
drainage    established    into    the    nose. 
The   posterior  wall   was    also   eroded 
and     the     meninges     were     separated 
from   the   sinus    only   by    the    perios- 
teum.   Healing  was  prompt  and  with- 
out    incident.      In     two     weeks     the 
wound  was  closed  and  the  excursions 
of  the  eye  were  normal.    Uncorrected 
vision  was  now  5/7.5  in  each  eye.   W. 
C.    Posey    (Ophthal.    Rec,   xxiv,    116, 
Cysts. — Cysts  similar  to  those  ob- 
served   in    the    maxillary    sinus    have 
occasionally    been    observed    in    the 
frontal  sinus.     They  contain  a  green- 
ish  or   brownish    viscid    fluid,    some- 
times v^^ax-like,  which  is  voided  with 
difficulty  when  they  rupture.     A  very 
gradual  swelling,  accompanied  by  lit- 
tle   or    no    pain    about    the    brow,    is 
about  the  only  symptom  noted,  even 

though  the  osseous  walls  of  the  cyst 
are  being  thinned  by  pressure  until 
palpation  and  slight  compression  im- 
parts a  crackling,  parchment-like  sen- 
sation to  the  finger. 

Case  of  a  cyst  of  the  frontal  sinus 
in  a  man  of  56.  The  tumar  had  been 
growing  fifteen  years,  the  patient 
having  refused  operation  until  it 
measured  38  by  35  cm.  An  incision 
released  1800  Gm.  of  a  reddish 
brownish  fluid.  The  brain  was  found 
much  compressed,  while  the  bone 
had  been  worn  away.  The  case  is 
remarkable  from  the  absence  of 
brain  symptoms  and  of  pain  or  other 
sensation  except  the  discomfort  from 
the  large  tumor,  although  after  its 
removal  there  was  room  for  the  fist 
between  the  skull  and  the  brain. 
Herzenberg  (Deut.  med.  Woch.,  Nov. 
4,  1909). 

Osteoma. — Primary  osteoma  of  the 
frontal  sinus  is  rarely  encountered. 
It  grows  very  slowly,  and  finally  pro- 
duces considerable  deformity  of  the 
face.  At  first  the  growth  is  insidious, 
but  after  a  time  neuralgia  becomes  a 
leading  symptom,  with,  perhaps,  un- 
due sensitiveness  over  the  growth ; 
however,  even  under  pressure,  the 
latter  conveys  to  the  finger  a  sen- 
sation of  flinty  hardness.  Trans- 
illumination shows  darkness  on  the 
affected  side,  but  the  growth  is  sel- 
dom sufficiently  circumscribed  to  en- 
dow this  diagnostic  resource  with 
much  value.  An  X-ray  plate  affords 
aid  only  within  the  same  limitation. 

Case  of  osteomalacia  in  a  married 
woman,  aged  35,  who  had  been  op- 
erated on  fifteen  years  previously. 
The  main  orbital  projection  had  been 
removed,  with  marked  relief  to  the 
orbital  symptoms.  The  patient  con- 
sulted the  writer  because  of  severe 
pain,  obstruction  of  the  right  nos- 
tril, and  gradual  protrusion  of  the 
right  eyeball.  The  radiograph  gave 
most  valuable  information   as   to   the 



position  and  extent  of  the  exostosis. 
A  curved  incision  was  made  from  the 
middle  of  the  right  ej^ebrow  to  the 
right  ala  nasi.  The  expanded  and 
thinned  covering  of  bone  was  clipped 
off,  and,  the  pedicle  of  the  growth 
attached  to  the  posterosuperior  wall 
of  the  frontal  sinus  having  been  di- 
vided, the  whole  growth  was  re- 
moved with  comparative  ease  by- 
means  of  a  strong  pair  of  forceps. 
The  growth  measured  2^  inches  in 
length  and  1J4  inches  in  breadth. 
The  wound  healed  by  first  intention. 
Jones  (Brit.  Med.  Jour.,  Nov.  17, 

In  examining  the  frontal  sinus,  an- 
trum and  ethmoidal  cells,  the  writer 
takes  first  a  lateral  view  of  the  face, 
and,  secondly,  an  anteroposterior  pic- 
ture with  the  tube  behind  the  head 
and  the  plate  in  front.  Anteropos- 
terior pictures  of  the  head  seldom 
show  as  well  in  print  as  in  the  orig- 
inal print  or  negative,  which  is  best 
examined  by  transmitted  light  in  a 
negative  examining  box.  Tousey  (N. 
Y.  Med.  Jour.,  Mar.  28,  1908). 

Malignant  Tumors. — Although  all 
forms  of  malignant  growths  in  this 
location  have  been  recorded,  epithe- 
lioma and  sarcoma  are  those  most  fre- 
quently observed.  The  symptoms 
being  practically  those  of  chronic 
sinusitis,  empyema,  and  mucocele,  an 
early  diagnosis  is  difficult.  Even  the 
advanced  signs,  such  as  prominence 
of  the  eyeball  with  diplopia,  amauro- 
sis and  pain,  are  common  to  other 
disorders.  Suggestive;  however,  is  a 
more  or  less  foul  discharge  from  the 
nose  when  it  is  streaked  with  blood 
and  detritus,  and  traced  with  pre- 
cision to  the  infundibulum,  or,  in  the 
case  of  sarcoma,  recurrent  hemor- 
rhages, traced  to  the  same  region. 
Swollen  glands  behind  the  angle  of 
the  jaw  may  suggest  malignancy. 

TREATMENT.  —  Mucoceles'  and 
cysts  can  sometimes  be  opened  in  the 

nasal  cavity  and  its  contents  evacu- 
ated. This  is  facilitated  by  causing 
constriction  of  the  surrounding  tis- 
sues by  means  of  a  4  per  cent,  solu- 
tion of  cocaine,  followed  by  spraying 
with  saline  solution.  In  most  cases, 
however,  the  contents  are  gelatinous 
and  cannot  be  evacuated  without  an 
incision  over  the  projecting  wall,  re- 
secting a  sufficient  portion  to  allow 
curetting  and  packing  with  iodoform 

Osteomata  require  enucleation; 
malignant  growths  likewise,  if  seen 
in  time.  Unfortunately,  their  prog- 
ress is  insidious  and,  as  a  rule,  they 
are  not  recognized  early  enough  to 
permit  successful  operative  measures. 


DERS.— The  ethmoid  cells  may  he 
the  seat  of  acute  and  of  chronic 

Acute  Inflammation;  Acute  Eth- 
moiditis. — The  proximity  of  the  an- 
terior ethmoidal  cells  to  the  frontal 
?nd  maxillary  sinus  exposes  them  to 
involvement  by  contamination,  while 
the  posterior  cells  are  exposed  to  it 
from  the  sphenoidal  cells.  Its  con- 
n.ection  with  the  nasal  cavity  exposes 
the  ethmoidal  sinus  to  the  catarrhal 
■disorders  and  to  occlusion,  nasal 
growths,  swellings,  etc.  Being  itself, 
besides,  liable  to  inflammatory  disor- 
ders, this  sinus  is  probably  more  fre- 
quently diseased  than  is  generally 
supposed,  and  the  underlying  seat  of 
many  stubborn  cases  of  chronic 

The  symptoms  of  acute  ethmoiditis 
are  not  always  clearly  defined.  The 
pain  is  usually  referred  to  the  orow 
and  behind  the  eyes,  but  sometimes 
only     persistent     headache     is     com- 



plained  of.  The  discharge  of  the  an- 
terior cells  follows  the  same  course 
as  those  of  the  antrum  and  frontal 
sinus,  its  elimination,  anteriorly  or 
posteriorly,  if  the  nasal  cavities  are 
free,  depending  upon  whether  the 
head  is  bent  forward  or  backward. 
Hence  the  fact  that  the  nasopharynx 
often  contains  accumulated  discharge 
in  the  morning  after  a  night  in  the 
recumbent  position.  The  acute  form, 
which  occurs  as  a  complication  of  ar 
acute  rhinitis  or  a  temporary  con- 
tamination from  a  neighboring  in- 
flammatory process,  disappears  when 
the  latter  ceases,  unless  imperfect 
drainage  prevents  it. 

Chronic  Inflammation  or  Chronic 
Ethmoiditis. — In  this  disorder  the 
inflammatory  process  initiated  by  a 
similar  process  in  the  neighboring 
sinuses  or  the  nose  persists.  In  one 
form,  the  hyperplastic,  the  mucosa  is 
swollen  and  gives  rise  to  a  watery 
discharge  which  is  irritating  to  the 
nose,  the  aire,  and  upper  lip.  There 
is  severe  boring  pain  either  in  the 
supraorbital  region,  suggesting  neu- 
ralgia, or  at  the  root  of  the  nose, 
radiating  toward  the  temples.  There 
may  be  a  sensation  of  pressure  in  the 
eyes,  muscse  volitantes,  and  also  an- 
osmia. The  pharynx,  larynx,  Eustach- 
ian tubes,  and  middle  ear  may  be 
involved  in  the  inflammatory  process. 
Asthma  is  sometimes  witnessed  in 
these  cases.  Acute  exacerbations  are 
common,  a  feature  which  leads  to 
atrophy  of  the  muciparous  glands, 
atrophy,  and  even  sclerosis.  The  se- 
cretion may  then  become  scanty  and 
form  a  tenacious  mass  which  dries 
and  forms  foul-smelling  crusts. 

The  second  form,  suppurative  eth- 
moiditis, dififers  from  the  former,  in 
that  the  discharge  is  purulent  instead 

of  merely  watery.  It  may  be  caused 
by  many  morbid  condition^ :  adjoin- 
ing catarrhal  disorders,  imperfect 
drainage,  syphilis,  tuberculosis,  ery- 
sipelas, influenza,  and  other  infec- 
tions, fractures,  operative  trauma- 
tisms, etc.  In  most  cases  met  with, 
however,  obstruction  of  the  outlet  of 
the  cells  beneath  the  middle  turbinate 
is  a  prominent  cause.  This  may  be 
due  to  the  viscidity  of  the  discharge, 
or,  as  is  often  the  case,  to  mechanical 
obstruction  in  the  middle  turbinate 
or  of  the  septum,  either  through 
osseous  malformation  or  hypertro- 
phy of  their  mucosa. 

An  important  feature  of  this  disor- 
der is  that,  owing  to  the  thinness  of 
the  partition  walls,  these  break  down 
easily  and  necrose,  giving  rise  to  a 
foul  discharge.  In  a  large  proportion 
of  cases  there  is  merely  a  copious 
purulent  outflow,  voided  through  the 
nose  or  nasopharynx,  the  latter  of 
which  it  reaches  from  the  superior  or 
middle  meatus.  The  pus  may  be 
sanious,  contain  bits  of  necrosed  tis- 
sues and  other  detritus,  and  give  off 
a  more  or  less  offensive  odor.  Pain 
is  rarely  observed  in  the  chronic 
form,  but  a  sensation  of  marked  dry- 
ness may  cause  considerable  discom- 

If  retention  of  the  pus  in  the  cells 
occurs  through  obstruction  of  their 
lumina,  serious  symptoms  may  be  de- 
veloped, such  as  congestion,  edema, 
bulging  of  and  pressure  in  eyeballs, 
sometimes  entailing  diplopia  and 
even  blindness  in  neglected  cases. 
Systemic  disturbances,  suggesting  py- 
emia, may  occur.  Mental  disorders 
and  meningitis  may  also  supervene  if 
the  pus  invades  the  cranial  cavity — a 
not  uncommon  complication,  which 
often  proves  rapidly  fatal.      Cerebral 



abscess  and  thrombosis  of  the  caver- 
nous sinus,  from  infection  of  the 
ethmoidal  veins,  may  also  occur. 
Fortunately,  the  most  usual  result  is 
rupture,  with  formation  of  a  fistula 
leading  externally  to  and  opening  be- 
low the  brow,  over  the  inner  angle  of 
the  eye.  The  pus  is  thus  eliminated 

The  diagnosis  of  acute  inflamma- 
tion of  the  ethmoidal  cells  should  be 
based  upon  careful  examination  of  the 
nasal  cavities.  The  above-described 
symptoms  are  all  observed  in  inflam- 
mation of  other  disorders.  Sugges- 
tive in  this  connection,  however,  is 
redness  of  the  lower  edge  of  the  mid- 
dle turbinate  and  extending  beneath  it. 
In  the  chronic  form,  a  purulent  dis- 
charge may  be  observed  in  this  loca- 
tion coursing  down  along  the  external 
wall  of  the  nose,  and  backward  over 
the  inclined  surface  of  the  inferior 

Latent  sinusitis  of  the  ethmoidal 
sinus  may  be  the  underlying  cause 
of  certain  reflex  neuroses.  A  simple 
operation  on  the  sinus  in  such  cases 
frees  the  patient  from  his  "neuras- 
thenia," "Meniere's  disease,"  "hay 
fever,"  "nervous  rhinorrhca"  or  other 
similar  complaints.  Menkes  (Nederl. 
Tijdsch.   V.    Geneesk.,   Apr.    12,    1919). 

Treatment. — Acute  inflammation 
of  the  ethmoidal  cells  is  mainly  per- 
petuated by  obstruction  of  their  out- 
let. The  treatment  recommended  for 
acute  inflammation  of  the  frontal 
sinus  in  this  section  is  also  indicated 
here.  In  chronic  inflammation  the 
causative  rhinitis,  septal  or  turbinal 
malformation  interfering  with  the 
drainage  of  the  cells  must  be  cor- 
rected. The  measures  indicated  un- 
der Chronic  Rhinitis  (see  page  72 
in  the  seventh  volume)  will  prove 
very  efficient.     Local  applications  of 

a  20  per  cent,  solution  of  argyrol, 
after  cleansing  the  nasal  cavity,  in- 
cluding the  middle  meatus,  with 
warm  saline  solution  is  highly  bene- 
ficial. This  weak  solution  of  argyrol 
may  also  be  used  with  an  atomizer 
provided  with  an  upward  tip,  which 
may  be  passed  under  the  middle  tur- 
binate. If  a  stronger  solution  (50 
per  cent.)  is  used,  the  applicator  is 
preferable.  Ichthiol  and  strong  solu- 
tions of  silver  nitrate,  which  some- 
times are  necessary,  should  only  be 
used  with  the  applicator.  The  possi- 
bility of  involvement  of  the  neighbor- 
ing sinuses  should  always  be  borne 
in  mind  and  adequate  treatment  car- 
ried out  if  needed. 

The  antrum  often  acts  as  a  reser- 
voir for  the  pus  originating  in  the 
ethmoidal  or  frontal  cells,  and  hence 
efforts  to  cure  an  antrum  abscess, 
without  first  curing  the  ethmoidal  or 
frontal  sinus  abscess,  prove  futile, 
while,  converse!}',  the  curing  of  the 
.  latter  will  usually  result  in  cure  of 
the  antrum  disease  without  any  at- 
tention being  directed  to  the  antrum 
itself.  Todd  (Jour.  Minn.  State  Med. 
Assoc,  and  N.  W.  Lancet,  Oct.  1, 

When  medication  does  not  suffice, 
owing  to  obstruction  ofifered  by  the 
middle  turbinate  to  the  drainage  of 
the  cells,  the  anterior  portion,  or  in 
severe  cases  the  whole  turbinate, 
should  be  removed.  By  placing  the 
diseased  cells  within  reach  of  the 
remedies,  and  insuring  efficient  drain- 
age and  ventilation,  this  procedure 
often  suffices.  When  this  does  not 
suffice,  the  ethmoid  cells  must  be 
opened  by  means  of  Hajek's  curved 
hook,  and  enlarged  with  Griinwald's 
forceps.  Saline  solution  irrigations 
mav  then  be  used  to  wash  out  the 
cells,  and  a  10  per  cent,  argyrol  spray 
to    promote    resolution,    which    often 



occurs.  If  it  does  not,  and  necrosed 
bone  be  found,  Bryan's  ethmoid  cu- 
rette should  be  used  to  remove  it 
while  continuing  the  irrigations. 
Considerable  care  is  necessary  in  this 
operative  procedure  to  keep  within 
the  limits  of  the  cells,  as  penetration 
of  the  cribriform  plate  above,  or  of 
the  external  cellular  walls,  may  en- 
tail serious  complications,  and  even 

The  writer  reports  2  fatal  cases  of 
suppurative  ethmoiditis  in  children, 
and  concludes  that  there  is  an  in- 
creasing conviction  that  acute  sup- 
purative ethmoiditis  causing  orbital 
and  cerebral  symptoms  is  not  so 
rare  a  condition  as  has  been  thought, 
and  that  it  is  often  rapidly  fatal, 
especially  in  the  young.  The  indi- 
cations for  operation  in  acute  eth- 
moiditis are  sudden  increase  in  tem- 
perature, delirium  at  night,  tumor 
formation  in  the  inner  wall  of  the 
orbit,  the  slightest  exophthalmos. 
Operation  should  not  be  delayed  too 
long.  As  in  appendicitis,  early  op- 
eration is  a  harmless  procedure,  late 
operation  generally  useless. 

When  there  is  bilateral  exophthal- 
mos, operation  is  generally  useless, 
as  the  disease  has  probably  extended 
through  the  cavernous  and  circular 
sinuses,  causing  a  general  toxemia 
and  pyemia,  or  fatal  brain  lesion. 
Krauss  (N.  Y.  Med.  Jour.,  Apr.  24, 

If  it  is  the  wish  of  the  operator  to 
clean  out  all  the  ethmoidal  cells,  the 
posterior  half  of  the  labyrinth  is  en- 
tered by  piercing  the  attachment  of 
the  middle  turbinate  and  by  curetting 
still  farther  backward,  using  all  the 
while  the  outer  side  of  the  middle 
turbinate  as  a  guide.  If  the  head  of 
the  patient  is  held  level,  the  middle 
turbinate  guides  the  curette  back- 
ward into  the  posterior  ethmoidal 
cell.  Often  the  posterior  half  of  the 
labyrinth  is  a  large  cavity,  made  up 
of  only  one  or  two  cells.  This  por- 
tion of  the  labyrinth  has  been,  as  it 

were,  exenterated  by  nature.  When 
the  curette  brings  up  against  the 
back  wall  of  the  labyrinth  the  re- 
maining part  of  the  middle  turbinate 
and  the  lower  half  of  the  superior 
turbinate  are  removed.  Then  the 
posterior  part  of  the  superior  turbi- 
nate is  taken  away,  flush  with  the 
front  face  of  the  sphenoidal  sinus. 
The  operator  now  recognizes  the 
inner  part  of  the  front  face  of  the 
sphenoidal  sinus,  which  is  free  in  the 
nasal  cavity,  and  the  outer  part  which 
has  a  common  wall  with  the  pos- 
terior ethmoidal  cell.  The  posterior 
outer  upper  angle  of  the  posterior 
ethmoidal  cell  is  dangerous  to  cu- 
rette or  to  probe.  It  is  of  the  utmost 
importance  that  the  operator  should 
be  sure  of  his  landmarks  in  this  lo- 
cality. He  orientates  himself  by  find- 
ing the  upper  rim  of  the  choana  and 
then  differentiating  the  free  face  of 
the  sphenoidal  sinus  by  proceeding 
upward  from  the  rim  of  the  choana 
close  to  the  septum.  Having  made 
out  the  extent  of  the  free  face  of  the 
sinus,  the  width  of  the  common  wall 
between  the  sphenoidal  sinus  and  the 
posterior  ethmoidal  cell  is  deter- 
mined. The  dividing  line  between 
the  two  parts  of  the  anterior  face 
of  the  sphenoidal  sinus  is  made  by 
the  obliquely  vertical  line,  which  is 
the  attachment  of  the  superior  tur- 

The  usual  mistake  made  by  the 
operator  is  to  get  lost  in  the  pos- 
terior ethmoidal  cell — that  is,  he  goes 
too  high  and  too  far  outward,  and 
considers  the  posterior  wall  of  the 
posterior  ethmoidal  cell  as  the  whole 
of  the  front  face  of  the  sphenoidal 
sinus.  This  mistake,  if  persisted  in, 
will  carry  him  into  the  brain.  In- 
sufficient removal  of  the  posterior 
part  of  the  superior  turbinate  and 
allowing  the  head  to  become  tipped 
upward,  are  the  chief  causes  of  this 
confusion.  After  the  landmarks  of 
the  front  face 'of  the  sphenoidal  sinus 
have  been  cleared  and  recognized,  the 
sinus  is  entered  near  the  septum — if 
possilile,  through  the  ostium — and 
the    whole    of    the    anterior    wall    re- 



moved.      II.     P.     Mosher     (Laryngo- 
scope, Sept.,  1913). 

Non-operative  treatment  of  infected 
sinuses,  a  suction  apparatus  being 
substituted,  advised.  The  author  has 
obtained  entirely  satisfactory  results 
and  has  discarded  oi)erative  work,  ex- 
cept on  the  antrum.  Illustrative  re- 
ports of  successfully  treated  cases  in- 
clude instances  of  severe  acute  fron- 
tal sinusitis;  acute  suppurative  of  the 
anterior  ethmoid  cells  with  orbital 
abscess;  acute  suppuration  of  the 
right  frontal  sinus;  chronic  suppura- 
tion of  the  frontal  sinus,  anterior 
ethmoid  cells,  and  antrum;  chronic 
suppuration  of  the  left  frontal  sinus, 
and  chronic  suppuration  of  the  pos- 
terior ethmoids  and  sphenoids.  E.  B. 
Gleason  (Laryngoscope,  18,  1,  1918). 

Benign  Tumors. — Mucocele  of  the 
ethmoidal,  irrespective  of  involve- 
ment of  the  other  sinuses,  is  occa- 
sionally met  with.  It  may  occur  as 
a  result  of  chronic  ethmoiditis,  espe- 
cially when  the  ostium  is  occluded,  or 
of  blocking  of  some  of  the  glandular 
acini.  The  tumor  may  fill  the  cell 
in  which  it  is  formed,  break  down 
the  thin  walls  between  the  cells,  or 
project  out  of  the  ostium  and  appear 
under  the  middle  turbinate.  Myxoma, 
osteoma,  fibroma,  and  other  benign 
growths  may  also  occur  in  this  loca- 
tion. All  the  growths  develop  in- 
sidiously, and  cause  no  pain,  until,  in 
some  instances,  nerves  are  com- 
pressed, extended,  or  affected  reflexly, 
or  the  neoplasm  encroaches  seri- 
ously upon  neighboring  structures 
and  deforms  them.  In  some  cases 
other  sinuses  are  penetrated  by  the 
growth  which  erodes  the  walls, 
separating  them. 

Case  of  a  lady  who  had  been  an- 
noyed for  several  months  by  a  very 
profuse    serous    discharge    from    the 

right  nostril  when  she  stooped.  This 
discharge  was  found  to  escape  from 
a  small  opening  in  the  top  of  carious 
bone  in  tlic  wall  of  the  bulla  eth- 
moidalis.  The  dividing  walls  of  the 
ethmoid  cells  had  all  been  destroyed, 
making  one  cavity  of  the  lateral  mass 
of  the  ethmoid  bone.  This  cavity 
was  hned  by  a  thin,  white,  glistening 
membrane,  the  typical  cyst  lining  in 
appearnce.  This  membrane  was  cu- 
retted lightly,  the  cavity  was  packed 
for  twenty-four  hours  to  control 
hemorrhage,  and  then  removed.  A 
month  later  it  was  reported  that  the 
only  change  was  that  the  discharge 
was  now  continuous,  whereas  for- 
merly it  had  taken  place  only  upon 
stooping.  Inspection  of  the  nose 
showed  a  free  opening  into  the  cyst 
with  fully  two-thirds  of  the  cavity 
covered  with  normal  membrane.  Six 
weeks  later  the  patient  reported  en- 
tirely well.  Thompson  (Laryngo- 
scope, Mar.,  1911). 

Malignant  Tumors. — Sarcoma  and 
epithelioma  of  the  ethmoidal  cells  is 
occasionally  observed  as  a  primary 
process.  In  epithelioma  the  growth 
may  be  very  insidious  and  be  discov- 
ered only  when  stifficiently  advanced 
to  cause  nasal  obstruction,  when  ex- 
amination reveals  its  presence.  A 
fetid  discharge  streaked  with  blood 
and  detritus  and  enlargement  of  the 
glands  behind  the  maxillary  bone  are 
suggestive.  Sarcoma  usually  pro- 
gresses more  rapidly,  and  is  apt  to  be 
attended  with  free  and,  sometimes, 
dangerous  hemorrhages. 

TREATMENT.— Surgical  removal 
is  alone  of  value.  Malignant  growths 
have  often  progressed  sufficiently  to 
involve  many  surrounding  structures 
when  first  seen — a  fact  which  greatly 
compromises  the  chances  of  recovery. 

Case  in  a  man,  aged  55  years,  who 
was  unable  to  breathe  through  the 
right  nasal  passage,  but  without  any 
other  symptom  of  distress.     The  pas- 



sage  was  found  filled  with  cauliflower 
excrescences  which  bled  at  the  slight- 
est contact  with  the  probe.  Poste- 
rior rhinoscopy  revealed  pretty  much 
the  same  aspect,  and  digital  explora- 
tion detected  a  soft  vegetative  mass 
covering  the  rhinopharynx,  the  right 
choana,  and  reaching  from  the  roof 
to  the  soft  palate,  barely  passing  the 
middle  line,  and  consequently  leav- 
ing a  free  space  upon  the  right  side. 
On  diaphanoscopy,  the  frontal  maxil- 
lary sinuses  became  illuminated  nor- 
mally. The  mass  was  removed  by 
external  access  with  a  good  deal 
of  hemorrhage,  necessitating  several 
tamponings.  The  middle  and  the  su- 
perior turbinates  were  destroyed,  the 
anterior  ethmoidal  cells  resected  to 
the  cribriform  plate  of  the  ethmoid, 
and  the  septum  was  resected  in  its 
posterior  portion.  Every  suspicious 
surface  was  thoroughly  curetted,  and 
hemorrhage  arrested  by  tamponing 
the  nasal  fossse  with  iodoform  gauze, 
and  the  skin  wound  united  with  su- 
tures. Recovery  was  good.  Fifteen 
months  later  the  patient  still  breathed 
freely,  and  his  nasal  fossa  did  not 
exhibit  any  trace  of  the  growth. 
Audibert  (Revue  Hebd.  de  Laryn., 
d'Otol.  et  de  Rhin.,  Feb.  24,  1912). 


DERS.— The  sphenoidal  cells  may  be 
the  seat  of  acute  and  of  chronic 

Acute  Inflammation.  —  Acute  in- 
flammation of  the  sphenoidal  sinus 
may  occur  as  an  extension  of  a 
similar  process  in  the  neighboring 
sinus,  or  the  nasal  and  nasopharyn- 
geal cavities.  It  is  identified  with 
difficulty;  the  symptoms — a  dull, 
deep-seated  headache,  referred  by 
some  patients  to  the  occipital  region, 
and  by  others  to  "somewhere  behind 
the  eyes" — constitute  about  all  the 
subjective  symptoms  which  suggest 
this  disorder.     Inspissated  mucus,  ac- 

cumulated in  the  postnasal  space,  to 
the  exclusion  of  the  anterior  nasal 
cavities,  and  voided,  as  a  rule,  is  an- 
other suggestive  fact.  In  some  cases 
these  symptoms  persist  and  consti- 
tute a  mild  "postnasal  catarrh."  In 
others,  they  disappear  spontaneously. 

Chronic  inflammation  or  empyema 
of  the  sphenoidal  sinus  may  be  due  to 
infection  by  neighboring  purulent 
process  in  the  other  sinuses  or  nasal 
cavities,  or  syphilis,  tuberculosis,  or 
fractures  of  the  base  involving  the 
sphenoid.  Besides  the  symptoms  ob- 
served in  the  acute  form,  neuralgia 
throughout  the  distribution  of  the 
fifth  pair  may  be  experienced,  tinni- 
tus and  vertigo  likewise.  The  dis- 
charge, instead  of  mucoid,  is  now 
mucopurulent  and  fetid,  and  tends  to 
accumulate  about  the  posterior  end 
of  the  middle  turbinate,  and  to  pass 
down  into  the  nasopharynx.  When 
swallowed,  especially  if  other  sinuses 
are  afifected,  which  is  often  the  case, 
gastric  disturbances  and  nausea  may 
be  caused. 

When  obstruction  of  the  sphenoidal 
orifice  occurs,  the  symptoms  in- 
crease greatly  in  severity,  severe 
pain,  insomnia,  a  febrile  reaction  oc- 
curring promptly.  Extension  of  the 
inflammatory  process  to  the  brain  is 
sometimes  observed.  As  the  disten- 
tion increases,  ocular  phenomena  ap- 
pear, which  may  include  congestion 
of  the  conjunctiva,  swelling  of  the 
lids,  and  even  amaurosis,  owing  to 
compression  of  the  optic  nerve.  The 
swelling  may  block  the  posterior 
choane  and  cause  violent  aural  symp- 
toms. Rupture  may  occur  into  the 
ethmoidal  cells,  the  orbit,  or  the 
skull,  and  cause,  in  the  latter  case, 
rapidly  fatal  meningitis. 

The    diagnosis    of    sphenoidal    em- 



pyema  is  based  mainly  upon  the 
simultaneous  presence  of  a  persistent 
discharge  into  the  posterior  nares, 
traced  above  the  vault  area,  and  pain 
in  the  back  of  the  head,  after  exclud- 
ing tlie  other  sinuses. 

The  writer  has  devised  an  instru- 
ment which  can  be  introduced  into 
the  pharynx  by  way  of  the  mouth 
and  which  carries  a  miniature  plate, 
so  that  this  can  be  brought  into  con- 
tact with  the  wall  of  the  sphenoid. 
By  X-ray  illumination  through  the 
frontal  region  of  the  cranium  from 
above,  an  accurate  picture  can  be  ob- 
tained of  the  sphenoidal  sinuses.  The 
method  is  simple  and  yields  valuable 
information  regarding  this  region 
hitherto  so  difficult  to  photograph. 
Bela  Freystadtl  (Berl.  khn.  Woch., 
July  13,  1914). 

TREATMENT.  — The  treatment 
of  intiammatory  disorders  is,  in  the 
main,  similar  to  that  of  other  sinuses 
reviewed.  After  applying  a  10  per 
cent,  solution  of  cocaine  to  the  space 
between  the  middle  turbinate  and  the 
septum,  which  will  contract  not  only 
the  tissues  of  these  structures,  but 
also  those  around  the  sphenoidal  open- 
ing, a  sphenoidal  cannula  is  passed 
into  the  latter,  and  the  cavity  washed 
out  with  saline  solution.  Irrigation 
cannot  be  done  sometimes  without 
creating  an  opening  in  the  most  de- 
pendent portion  of  the  sinus  by 
means  of  a  gouge  passed  along  the 
surface  of  the  middle  turbinate, 
p)ointing  the  instrument  upward  and 
backward,  under  posterior  rhinoscopy. 
Too  big  an  opening  by  allowing  the 
escape  of  a  large  quantity  of  pus  to 
escape  may  cause  syncope,  hence  a 
small  opening  is  preferable  at  first. 
The  curette  is  sometimes  necessary, 
followed  by  saline  solution  irriga- 
tions and  the  local  application  of  a 
10  per  cent,  solution  of  argyrol. 

Although    it    is    not    necessary    to 
have  the   ostium    in   view   in   passing 
a  sound,   to   the   author's   mind   it   is 
absolutely  demanded  when  operative 
measures  are  about  to  be  undertaken; 
the  anatomic  relations  of  the  superior 
wall  to  the  optic  nerve  and  the  pitui- 
tary   body    and    the    lateral    walls    to 
the  sinus   cavernosus  and  carotid   ar- 
tery, to  say  nothing  of  the  brain  it- 
self,  makes   this  region  of   operating 
one    of    extreme    danger,    unless    the 
operator    has    perfect    vision    of    the 
entire  field.     The  lateral  wall  of  the 
nose,   as    well    as   the   septum,    is   co- 
cainized with  a  20  per  cent,  solution, 
the     posterior     half     of     the     middle 
turbinate    is    removed,    the    posterior 
ethmoid    cells     are    broken    through 
with   Hajek's   ethmoid  hook,   and   the 
debris     removed     with     a     Griinwald- 
Hartmann    conchotome    or    a    similar 
instrument.     The   evulsor  is  then   in- 
serted in  the  ostium  and  the  opening 
enlarged  by  a  few  well-directed  pulls; 
this    is    followed    by    the    use    of    the 
bent    forceps    of    Hajek    and    enough 
bone  is   removed   as  to  insure  a  per- 
manent  opening,  which   should  reach 
as  far  as  the  floor  of  the  nose.    Com- 
plete   healing   usually   takes   place    in 
from   three    to    eight  weeks,   depend- 
ing   on    the    degree    of    inflammation 
and  the  extent  of  the  operative  inter- 
ference.    The  advantages  of  this  op- 
eration is   that   a  full   field  is   always 
in   sight;   the   preliminary  opening  of 
the    sphenoid    from    within    outward 
thereby     incurs     no     danger    to    the 
structures    behind;    and    there    is    a 
permanent  opening  which  lessens  the 
danger  of  recurrence.     Ross  H.  Skil- 
lern   (Jour.  Amer.  Med.  Assoc,   Dec. 
19,   1908). 

The  writer  anesthetizes  the  nose 
with  cocaine  and  epinephrin,  and 
punctures  the  anterior  wall  of  the 
sinus  at  its  lower  and  internal  por- 
tion. In  the  absence  of  any  obstruc- 
tive deformity  of  the  upper  part  of 
the  septum  nasi  this  can  be  readily 
accomplished  in  the  vast  majority  of 
cases,  and  no  removal  of  nasal  tissue 
is    necessary.     This   opening  has   the 



further  advantage  of  being  in  the 
best  position  for  drainage  of  the  cav- 
ity. The  operation  is  free  alike  from 
pain,  hemorrhage,  and  danger.  If  the 
cavity  is  normal  the  wound  will  have 
closed  in  twenty-four  hours.  If  the 
sinus  is  infected  the  operation  affords 
the  best  possible  opportunity  for 
making  an  early  and  accurate  diag- 
nosis and  for  the  employment  of 
suitable  measures  for  local  treatment, 
particularly  lavage  and  drainage.  C. 
P.  Grayson  (Penna.  Med.  Jour.,  Apr., 


Benign  Tumors.  —  Myxomata  and 
osteomata,  occasionally  found  in  this 
sinus,  are  harmful  mainly  because 
they  tend  early  to  produce  obstruc- 
tion, and,  therefore,  bring-  on  em- 
pyema. As  the  tumor  grows  it  brings 
on  pressure  symptoms,  blindness  or 
optic  neuritis,  when  the  optic  nerve 
is  compressed;  exophthalmos  of  the 
eyeball,  etc. 

Malignant  Growths.— These  pro- 
duce phenomena  similar  to  those  just 
described  when  they  have  progressed 
sufficiently  to  do  so.  A  purulent  san- 
guinolent  discharge  in  the  vault, 
traced  upward  to  the  sphenoidal 
opening,  is  about  the  only  early  sign 

TREATMENT.— The  location  of 
the  sphenoid  renders  operative  re- 
moval impracticable,  especially  in 
view  of  the  fact  that  the  cases  are 
usually  far  advanced  when  they 
reach  the  specialist. 

C.  E.  DE  M.  Sajous, 


SKIN-GRAFTING. -When  skin 
grafts  are  obtained  from  the  patient 
himself,    they    are    called    autografts; 
when    from    another    person,    homo- 
grafts;  and  when  from  animals,  coo- 

gra'ffs.  The  best  results  are  derived 
from  autografts.  Homografts  grow 
better  than  zoografts,  but  it  must  not 
be  forgotten  that  they  may  cause  dis- 
ease, especially  syphilis,  and  that  they 
may  break  down  and  disappear  upon 
slight  provocation. 

Reverdin's     Method.— With     fresh 
wounds   or   healthy   granulating  sur- 
faces  little  preparation   is   necessary. 
Freedom  from  suppuration  would,  of 
course,  be  desirable,  but  it  is  seldom 
attainable.      When    the    granulations 
are   not  in   good   condition   an   effort 
should  be  made  to  render  them  firm, 
red  and  healthy  by  pressure,  by  re- 
peated cauterization  with  stick  nitrate 
of  silver,  or  by  painting  them  occa- 
sionally with  tincture  of  iodine.     Leg 
ulcers  may  often  be  much  improved 
by  elevation  of  the  extremity.     Cal- 
lous ulcers  should  have  radiating  in- 
cisions made  in  their  borders.     Foul 
ulcers  must  receive  preliminary  anti- 
septic    treatment,     and     all     sloughs   • 
should  be  cleared  away  before  graft- 
ing is  attempted. 

The  grafts,  which  are  best  obtained 
from  the  arm  or  thigh,  should  be 
about  the  size  of  a  grain  of  wheat. 
They  are  cut  by  elevating  a  portion 
of  skin  with  mouse-toothed  forceps 
and  dividing  it  with  scissors  curved 
on  the  flat,  removing  the  entire  epi- 
thelium and  a  portion  of  the  corium 
without  disturln'ng  the  subcutaneous 
fat.  The  bits  of  cuticle  adhere  to  the 
surface  to  be  grafted,  especially  if 
gentle  i)ressure  with  a  pledget  of 
gauze  be  employed.  Nothing  is 
gained  by  scraping  or  m  any  way 
wounding  the  granulations.  The 
transplantations  should  be  close  to- 
gether, as  the  greatest  size  to  which 
a  graft  can   grow  is  perhaps  that  of 

a   silver  dime.      Excellent  grafts   can 



be  cut  with  sharp-pointed  scissors 
from  the  delicate  pellicle  of  new  skin 
which  pushes  out  from  the  borders 
of  a  healing  ulcer  (Souchon).  Imme- 
diately over  the  grafts  may  be  placed 
strips  of  rubber  protective,  or  a  single 
layer  of  gauze,  which  may  be  pinned 
around  a  limb  or  fastened  at  the 
edges  with  collodion.  Whether  the 
external  dressing  is  moist  or  dry  is 
usuall}^  of  little  importance,  but  no 
antiseptic  stronger  than  boric  acid 
should  be  used.  As  there  is  gener- 
ally some  suppuration,  it  is  necessary 
to  change  the  superficial  portion  of 
the  dressing  every  twenty-four  hours 
at  least,  leaving  in  place  the  rubber 
tissue,  or  the  undermost  layer  of 
gauze,  as  the  case  may  be.  Gentle 
irrigation  with  a  solution  of  salt  or 
boric  acid  assists  in  maintaining 
cleanliness.  The  open  method  of 
dressing  has  recently  come  into  use, 
and  may  often  be  employed  to  ad- 
vantage. In  this  the  grafts  are  left 
entirely  uncovered,  being  protected 
from  injury  by  placing  over  them  a 
"cage"  made  of  wire  gauze  (a  kitchen 
"strainer"  for  instance).  The  edges 
of  the  gauze  are  bound  with  adhesive 
plaster,  a  few  strips  of  which  may  be 
utilized  to  hold  the  cage  in  position. 

Thiersch's  Method. — There  is  no 
process  of  skin-grafting  so  simple,  so 
reliable,  and  so  generally  applicable 
as  this.  It  is  of  great  value  in  the 
treatment  of  ulcers,  burns,  and  de- 
fects following  operations  or  injuries. 

The  patient  is  anesthetized,  and  if 
granulations  are  present,  it  is  best  to 
scrape  them  away  with  a  sharp  spoon 
down  to  the  comparatively  firm  tissue 
beneath,  although  this  is  not  abso- 
lutely necessary.  Oozing  is  checked 
by  elevation  and  pressure,  an  Es- 
march  strap  being  unnecessary.    The 

grafts  are  cut  with  a  razor  from  the 
anterior  surface  of  the  thigh  or  upper 
arm.  An  assistant  makes  the  skin 
tense  by  means  of  a  hand  on  either 
side  of  the  limb,  while  the  operator, 
standing  with  his  back  toward  the 
patient's  feet,  cuts  toward  himself, 
with  his  left  hand  stretching  the  tis- 
sues in  the  direction  of  the  knee. 
With  a  backward  and  forward  saw- 
ing motion  it  is  not  difficult  to  obtain 
shavings  of  epidermis  an  inch  or 
more  wide  and  several  inches  in 
length,  and  as  thin  as  paper:  No 
objectionable  scar  results.  The  deli- 
cate strips  of  cuticle  fold  up  on  the 
blade  of  the  razor,  from  which  they 
may  be  spread  directly  upon  the  sur- 
face to  be  grafted,  and  so  adjusted 
that  they  overlap  each  other  and  the 
edges  of  the  skin,  completely  con- 
cealing the  raw  surface.  Healing 
without  suppuration  is  not  uncom- 
mon. Over  the  transplanted  cuticle 
are  placed  strips  of  rubber  tissue,  a 
single  layer  of  gauze,  or  simply  a 
wire  cage  as  described  in  the  Rever- 
din  method.  Davis  uses  a  coarse- 
meshed  net,  such  as  is  used  for  cur- 
tains, for  "splinting"  the  grafts  in 
position.  The  stiffening  is  washed 
out  and  the  net  is  soaked  in  gutta- 
percha 30  parts,  chloroform  150  parts, 
and  is  sterilized  by  keeping  in  a 
1 :  1000  solution  of  mercury  bichloride. 
If  a  moist  dressing  is  employed,  it 
should  consist  of  a  thick  pad  of  gauze 
saturated  with  normal  salt  solution 
and  covered  with  cotton  and  oiled 
silk.  This  should  be  renewed  often 
enough  to  keep  it  moist.  A  dry 
dressing  answers  equally  well,  ap- 
plied as  in  the  treatment  of  ordinary 
wounds.  The  grafts  do  not  become 
firmly  fixed  for  nine  or  ten  days,  and 
it  is  well  not  to  soak  off  the  under- 


most   layer   of  gauze   for   about   two  is  unfavorable  for  their  existence.     In 

weeks.  five   to   seven   days   the   granulations 

The      Wolfe-Krause      Method, — In  are   cut    from    above   and    the   grafts 

this     method     grafts     are     employed  exposed. 

which  fill  the  entire  defect,  and  which  In  caterpillar  grafting,  which  really 
comprise  the  whole  thickness  of  skin  belongs  to  plastic  surgery  rather  than 
without  the  subcutaneous  tissues,  to  skin-grafting,  a  long,  narrow,  full- 
The  fat  may  also  be  included  if  de-  thickness  flap  (about  1  inch  by  5 
sired,  although  the  chance  of  success  inches)  is  dissected  up  from  the  ad- 
is  less  (Hirschberg).  In  cutting  the  jacent  integument  with  its  base  close 
skin  at  least  one-third  must  be  al-  to  the  area  to  be  grafted.  The  distal 
lowed  for  shrinkage.  Sutures  are  extremity  is  then  stitched  close  to  the 
usually  unnecessary  and  artificial  heat  base,  thus  humping  the  flap  up  in  its 
is  detrimental.  center,  much  as  a  caterpillar  crawls. 

Wolfe's  original  method  has  been  After  union  of  the  tip  has  taken  place 
modified  and  the  technique  improved  in  this  position,  the  base  is  loosened 
by  Krause,  who  employs  spindle-  and  the  flap  straightened  out  upon 
shaped  grafts,  so  that  the  wound  the  granulating  surface.  The  oc- 
produced  by  their  removal  may  be  casions  are  not  numerous,  however, 
sutured  immediately.  The  pieces  of  in  which  this  "crawling"  procedure 
skin,  cut  into  smaller  pieces,  if  desir-  is  preferable  to  free  grafting, 
able,  are  accurately  fitted  into  the  Subcutaneous  Skin-grafting.  —  Un- 
defect  which  is  to  be  closed.  The  der  ordinary  circumstances  skin- 
operation  must  be  a  "dry"  one,  and  grafts  cannot  be  used  beneath  the 
the  raw  surfaces  of  the  skin  should  surface  of  the  body  owing  to  the 
be  handled  as  little  as  possible.  danger  of  infection.     Rehn  has  dem- 

Skin-periosteum-bone      grafts      are  onstrated,  however,  that  this  can  be 

sometimes  employed.     They  are  cut  done  with    more   or   less    success   by 

out  bodily,  from  the  tibial  region,  for  shaving  off  the  superficial  portion  of 

instance,  without  disturbing  the  con-  the  transplant,  thus  mechanically  re- 

nections   of  the   component   parts   to  moving  the  bacteria.     Grafts  of  this 

each  other.  character   have    been    employed  as   a 

Two  curious  methods  of  skin-graft-  substitute  for  lost   tendons,   to   close 

ing  introduced  by  MacLennan  should  the  pylorus,  etc.,  but  it  would  seem 

be  mentioned,  although  they  are  sel-  that    less    complicated    methods    are 

dom  employed.     They  are  known  as  preferable,  such  as  the  use  of  fascia 

"tunnel     grafting"     and     "caterpillar  lata, 

grafting."  Anomalies     in     Grafting.  —  Trans- 

In  tunnel  grafting  small  grafts  are  plantation  of  the  mucous  membrane 

slipped  beneath  the  granulations  into  may  be  made.     It  may  be  shaved  off 

little  "tunnels"  made  for  the  purpose,  as     in     skin-grafting, — for     instance, 

where  they  are  surrounded  by  ])l()od-  from  the  lips, — or  it  may  be  stripped 

clot  and  protected  from  external  in-  off  in  its  entirety. 

jury,  which  is  supposed  to  facilitate  More    or    less    satisfactory    results 

their  growth  under  certain  conditions,  can  be  obtained  by  the  use  of  shav- 

especially  where  the  granular  surface  ings  of  callus  from  the  palms  of  the 


hands  or  soles  of  the  feet,  or  from  comes  in  time  movable,  but  that  pro- 
sections  of  corns.  "Epithelial  rods"  duced  from  Reverdin  grafts  remains 
from  warts  have  been  successfully  immovable,  owing-  to  cicatricial  tissue 
used,  as  have  also  flakes  of  old,  dried  between  the  individual  bits  of  cuticle. 
epidermis  from  various  parts  of  the  Hairs  may  remain  where  transplanta- 
body;  even  "epithelial  dust"  scraped  tions  of  the  entire  thickness  of  the 
from  the  surface  of  the  skin  will  skin  are  made,  but  they  are  apt  to 
often  grow  on  a  granulating  wound,  become  deformed  or  fall  out.  But 
Deeper  scrapings,  drawing  sufficient  little  postoperative  contraction  takes 
blood  to  form  a  paste  which  may  be  place  in  the  Thiersch  and  Wolfe- 
spread  upon  a  raw  surface,  are  said  Krause  methods,  but  in  the  method 
to  be  quite  satisfactory  at  times  of  Reverdin  contraction  is  apt  to  be 
(Mangoldt).  considerable.      Exfoliation   of  epider- 

Grafting  from  dead  bodies  or  from  mis  may  occur  in  any  form  of  graft- 
amputated  limbs  has  frequently  been  ing,  but  this  does  not  necessarily 
resorted  to,  but  the  chance  of  success  mean  that  the  grafts  are  dead.  A 
is  not  great,  and  the  danger  of  carry-  remarkable  phenomenon  in  connec- 
ing  disease  cannot  be  disregarded.  tion    with    Thiersch    grafting    is    the 

Sponge-grafting  is  now  seldom  em-  readiness  with  which  depressions  fill 

ployed.     Very   thin   slices   of  sponge  up   to   a   level   with   the   surrounding 

are  sterilized  by  boiling,  and  placed  skin. 

upon  the  raw  surface.     The  material  In   plastic   work   about   the   face  it 

acts    as    a    framework    only    for    the  should  always  be  borne  in  mind  that 

granulations,  and  is  soon  absorbed.  flaps   of    skin   from    the   vicinity,   for 

The  idea  of  grafting  from  animals  instance  from  the  neck,  are  preferable 
is  attractive,  but  the  results  are  too  to  free  grafts,  especially  the  thinner 
uncertain,  and  the  method  has  largely  ones,  because  their  color  and  con- 
fallen  into  disuse.  Skin  has  been  sistency  will  conform  more  nearly  to 
obtained  from  frogs  (abdomen),  that  of  their  surroundings,  thus  ren- 
chickens  (beneath  the  wings),  pigs,  dering  them  far  less  conspicuous, 
dogs,  cats,  rabbits,  guinea-pigs.  etc.  COMPARISON  OF  METHODS. 
Cocks'  wattles,  sections  of  the  testi-  — The  simplest  is  that  of  Reverdin, 
cles  of  rabbits,  amniotic  membrane,  although  the  new  skin  is  often  little 
and  the  lining  membrane  of  eggs  better  than  scar-tissue.  It  should  be 
have  also  been  employed.  reserved    for   cases    where    the    rapid 

HISTOLOGY  AND  PATHOL-  closure  of  a  granulating  surface  is 
OGY. — The  existence  of  epithelial  desired  without  reference  to  anything 
grafts  may  be  said  to  be,  for  a  time,  else.  Thiersch  grafting  has  a  wider 
parasitic.  In  the  course  of  about  range  of  applicability  than  anv  other 
eighteen  hours  vascular  connections  method,  and  its  results  are  uniformly 
begin  to  form,  firm  adherence  taking  good,  both  functionally  and  cosmetic- 
place  by  the  tenth  day.  Successful  ally ;  but  it  must  give  way  to  the 
grafts  soon  become  pinkish  in  color.  Wolfe-Krause  process  when  thicker 
New  skin  arising  from  large  grafts,  skin  is  desired,  which  more  closely 
which  cover  the  entire  raw  surface  resembles  the  surrounding  integu- 
(Thiersch    and    Wolfe    grafts),    be-  ment.     It  may  sometimes  be  expedi- 



ent  to  graft  from  dead  bodies  or  from 
amputated  limbs;  and  occasionally 
use  may  be  found  for  "epidermal 
scrapings,"  or  for  epidermis  obtained 
from  warts,  corns,  callosities,  blisters, 
etc.,  but  one  must  not  expect  the 
results  to  be  brilliant. 

The  skin  of  animals  does  not  com- 
pare in  vitality  with  that  taken  from 
a  patient's  own  body,  or  even  from 
some  other  person.  It  is  seldom 
necessary  to  transplant  from  mucous 
membrane,  as  ordinary  Thiersch 
grafting  answers  the  same  purpose  in 
nearly  all  cases. 

Leonard  Freeman, 




— A  wen  (steatoma)  is  a  cystic  tumor 
varying  in  size  from  a  millet-seed  to  an 
orange,  formed  by  the  retention  of  secre- 
tion in  a  sebaceous  gland,  and  situated 
in  the  skin  or  subcutaneous  structures. 
Wens  occur  most  frequently  on  the  scalp, 
face,  back,  and  scrotum,  and  may  be 
single  or  multiple.  The  contents  of  these 
tumors  are  milky  or  cheesy  in  character, 
but  if  the  tumor  be  injured,  inflammation 
and  ulceration  may  follow,  or  in  the  aged 
the  tumor  may  acquire  a  malignant  char- 
acter,  degenerating  into   epithelioma. 

Treatment. — A  cure  will  be  effected  by 
making  an  incision  in  the  skin  down  to 
the  cyst  and  carefully  dissecting  it  out. 
Incision  and  mere  evacuation  of  the  con- 
tents are  always  followed  by  a  return  of 
the   tumor. 

FURUNCLE.  —  Furuncle  (furunculus ; 
boil)  is  a  local  inflammatory  affection  of 
the  skin,  commonly  involving  a  cutane- 
ous gland  or  hair-follicle.  They  may  oc 
single  or  multiple,  and  may  appear  in 

The  diagnosis  of  the  affection  is  usu- 
ally quite  easy.  It  may  sometimes  be 
confounded  with  carbuncle.  General  ap- 
pearance, single  opening,  and  circum- 
scribed character  usually  distinguish  the 

Etiology. — Improper  diet  and  hygiene, 
nervous  depression,  overwork,  too  free 
indulgence  in  greasy  foods  and  gravies, 
and  irregular  action  of  the  bowels,  local 
irritation,  friction,  and  prolonged  poultic- 
ing predispose  to  this  affection.  The  en- 
trance of  pus-cocci  into  the  skin  is  the 
essential  or  exciting  cause  of  this  dis- 
order. Single  boils  are  usually  the  result 
of  local  irritation;  their  appearance  in 
successive  crops  (furunculosis)  is  usually 
an   indication   of   impaired   health. 

Treatment. — Removal  of  the  cause  and 
regulation  of  the  diet  claim  first  attention. 
Open-air  exercise  and  tonics  are  useful  in 
debilitated  sul)jects.  Strong  ammonia, 
caustic  potash,  acid  mercury  nitrate,  and 
other  forms  of  caustic  have  been  used  to 
abort  in  the  early  stage.  Yeast,  nuclein, 
quinine,  and  mineral  acids  have  been 
given  to  prevent  recurrence.  Arsenic, 
with  or  without  iron,  is  sometimes  bene- 
ficial. Sodium  sulphite  or  thiosulphate 
(IS  to  30  grains — 1  to  2  Gm.— every  three 
hours),  calx  sulphurata  (%  grain — 0.008 
Gm. — every  two  or  three  hours),  or  sul- 
phur may  be  given  internally.  A  solution 
of  boric  acid  or  of  sublimate,  a  10  per 
cent,  salicylic  acid  ointment,  or  a  mix- 
ture of  equal  parts  of  ichthyol  and  col- 
lodion may  be  applied  locally.  White  has 
used  full  doses  of  mercury  bichloride  in- 
ternallj'    to    prevent    recurrence. 

Hypodermic  antiseptic  injections  into 
the  very  base  of  a  boil  or  carbuncle,  early 
in  its  history,  are  practically  an  unfailing 
means  for  aborting  an   attack. 

Heat  is  directly  injurious  to  the  mi- 
crobes of  furunculosis;  active  hyperemia 
is  induced,  and  the  skin  sterilized;  the 
profuse  sweating  induced  prevents  rapid 
increase  of  temperature  in  the  deeper 
tissues.  The  hot  air  is  first  applied 
around  the  circumference  of  the  affected 
part,  and  then  to  the  boil  itself.  Two  or 
three  applications  are  given  on  the  first 
day,  and  one  daily  afterward.  Temper- 
ature  of  air,  250°   F.    (120°    C.). 

CARBUNCLE.— Definition.— Carbuncle 

(carbunculus;  it  is  erroneously  called 
benignant  anthrax,  or  anthrax")  is  a  hard, 
circumscribed,  deep-seated,  painful  inflam- 
mation of  the  subcutaneous  tissue,  ac- 
companied by  chill,  fever,  and  constitu- 
tional   disturbance,    and    attended    almost 



always     with     circumscribed     suppuration 
and   the   formation   of  a  slough. 

Symptoms. — The  local  symptoms  are 
heat  and  aching,  with  throbbing  and  great 
tenderness,  which  are  often  followed  by 
pain  and  redness  along  the  lymphatics  of 
the  part  and  pain  and  swelling  in  the 
nearest  lymphatic  glands.  There  is  at 
first  a  chill,  followed  by  a  febrile  move- 
ment, which  is  generally  well  marked, 
and  often  very  severe.  The  constitu- 
tional symptoms  resemble  those  of  ery- 
sipelas very  closelj^  and  may  be  as  se- 
vere as  those  of  the  severest  forms  of 
that  disease,  and  the  consequences  may 
be  fully  as  grave  and  fatal. 

Diagnosis, — The  size  of  the  inflamed 
area,  flatness-  of  surface,  multiple  open- 
ings or  points  of  suppuration  and  exten- 
sive slough  differentiate  carbuncle  from 
furuncle.  Carbuncle  is  single,  furuncle 
generally  multiple. 

Etiology. — A  lowered  vitality  from  any 
cause  predisposes  to  this  affection.  It  is 
especially  common  in  diabetes.  Microbic 
infection  is  the  exciting  cause. 

Prognosis. — Carbuncle  is  especially  dan- 
gerous when  located  on  the  scalp,  abdo- 
men, and  upper  lip;  in  these  locations  it 
is  apt  to  occur  in  young  people,  and 
usually  runs  an  acute  course  and,  as  a  rule, 
is  fatal  from  pj-emia.  The  prognosis  is 
grave  when  extensive  and  attacking  the 
elderly,  especially  if  complicated  with 
Bright's  disease  or  diabetes.  The  prog- 
nosis should  always  be  guarded,  even  in 
the  most  hopeful  cases.  Death  is  not  in- 
frequent in  the  old  and   debilitated. 

Treatment. — General  tonics,  like  quinine 
and  iron,  with  large  amounts  of  nourish- 
ing food,  are  indicated.  Opium  or  other 
anodynes  may  be  required  to  relieve  pain 
and  procure  rest.  Stimulants  should  be 
given  only  when  required. 

Reynolds  advises  dilute  sulphuric  acid 
in  20-  to  30-  minim  (1.3  to  2  c.c.)  doses  in 
2  ounces  (60  c.c.)  of  water  every  four 
hours  (small  doses  are  useless),  with  5 
per  cent,  carbolized  petrolatum  locally. 

In  the  early  stage  10  to  20  minims 
(0.6  to  1.3  c.c.)  of  a  5  or  10  per  cent, 
solution  of  phenol  in  glycerin  may  be  in- 
jected into  the  central  portion  of  the  mass 
with  the  view  of  aborting  the  mischief. 
If  seen  later,  firm  compression  by  straps 

hi  adhesive  plaster  applied  concentrically 
may   be   made,   leaving   the   central   orifice 
free  for  the  discharge  of  sloughs  and  ap- 
plying   an    antiseptic    dressing    over    the 

Another  plan,  applicable  in  the  early 
or  late  stage  as  well:  Place  patient  un- 
der an  anesthetic;  freeze  the  parts  to 
make  them  friable;  make  one  long  in- 
cision or  several  crucial  incisions  through 
the  mass;  remove  all  sloughs  and  decay- 
ing tissue  with  a  sharp  curette;  disinfect, 
drain,  and  suture,  as  in  an  incised  wound. 

Another  method  of  treatment  is  the 
application  of  warm,  moist,  antiseptic 
dressings,  covered  with  thin  rubber  cloth 
or  oiled  silk,  removing  sloughs  as  soon 
as  loosened,  and  using  iodoform,  aristol, 
europhen,  or  similar  antiseptic  powder 
freely.  The  use  of  poultices  is  harmful 
and   should   be   avoided. 

The  use  of  autogenous  vaccine,  once  a 
week  in  dose  of  100  to  200  million  dead 
cocci  was  effectual.  Bier's  passive  hyper- 
emia by  means  of  band  around  lower  part 
of  the  neck  was  used  with  success  in 
carbuncles  of  the  face  and  high  up  on 
neck.  Mild  constriction  was  sufficient  for 
twenty  to  twenty-two  hours  daily  unless 
edema  appeared. 

Ichthyol  is  practically  a  specific  in  the 
treatment  of  carbuncles,  applied  pure,  so 
as  to  cover  the  entire  swelling,  except  the 
apex.  The  apex  on  which  the  ichthyol 
is  absent  is  covered  with  a  piece  of  cloth 
greased  with  tallow.  The  application  is 
renewed  once  a  day.  After  three  appli- 
cations the  surface  should  be  washed 
thoroughly  so  as  to  remove  the  varnish- 
like coating  which  the  ichthyol  forms  on 
drj'ing,  and  a  new  application  is  to  be 

Personal  experience  in  the  local  treat- 
ment of  carbuncle  with  liquid  air  has 
shown  A.  Campbell  White  that  this  is  by 
far  the  best  form  of  treatment.  It  is  less 
painful  to  the  patient  than  any  other  form 
of  treatment.  Only  one  application  is 
necessary.  In  the  treatment  by  liquid 
air  the  spray  is  used,  first  projecting  it 
into  the  openings  and  using  the  air  quite 
freely;  then  quite  thoroughly  freezing  the 
external  surface,  which  must  be  well 
cleansed  of  discharge  resulting  from 
sending    air    inside    the    carbuncle    before 



freezing.  After  freezing  the  carbuncle 
should  be  dressed  with  a  dry  absorbent 
dressing.  The  reaction  from  freezing 
takes  place  in  about  twenty  minutes,  and 
it  is  to  this  extreme  hyperemia  that  the 
success  of  liquid  air  in  the  treat- 
ment of  this  affection  is  attributed 
more    particularly. 

KERATOSIS  SENILIS.— This  affec- 
tion is  a  cornification  of  the  skin  of  old 
people,  general  or  partial,  circumscribed 
or  diffuse,  and  often  limited  to  the  face 
and  the  dorsal  surfaces  of  the  hands  and 
feet,  or  sometimes  the  forearm  and  chest. 
The  lesions  consist  of  light-  or  dark- 
yellow,  brownish  points,  dry  scaling  and 
horny,  or  scaling  and  greasy,  aggregated 
masses  of  an  irregular  circular  or  oval 
outline.  The  surface  of  these  masses  is 
insensitive,  and  may  project  about  an 
eighth  of  an  inch  above  the  surface. 
These  masses  may  be  readily  picked  off, 
leaving  a  small,  superficial,  smooth,  ex- 
coriated surface  or  one  covered  with 
minute  conical  elevations  (enlarged  se- 
baceous glands).  This  affection  rarely 
appears  before  the  fiftieth  year,  and  may 
not  claim  attention  until  fifteen  or 
twenty    years    later. 

Prognosis. — The  prognosis  is  favorable 
if  the  proper  treatment  is  promptly  ap- 
plied. When  left  alone  the  pigmented 
masses  are  prone  to  epitheliomatous  de- 
generation, and  may  become  foci  for 
carcinoma  of  the  face,  in  which  case  the 
dry  scales  are  displaced  by  a  scab,  the 
tissues  become  hard,  and  growth  is  more 

Treatment. — In  the  early  stage,  in- 
unctions with  petrolatum  or  olive  oil 
and  the  subsequent  use  of  soap  and  warm 
water  will  remove  the  trouble.  When  the 
masses  are  firmer,  ointments  should  be 
applied  at  night,  and  soft  soap  or  sapo 
viridis  in  the  morning,  removing  the 
soap  by  carefully  washing  with  clean, 
warm  water;  applications  of  diachylon 
ointment  will  heal  any  excoriations  that 
may  have  been  produced.  When  marked 
projection  of  the  mass  is  present,  the 
thorough  use  of  the  curette,  or  nitric 
acid  on  a  pointed  stick,  well  worked  into 
the  parts,  will  remove  the  affected  tis- 
sues. If  epitheliomatous  change  is  sus- 
pected,   prompt   excision   is   indicated. 

CLAVUS  (CORN).— Clavus  is  an  hy- 
perplasia of  the  corneous  or  horny  layer 
of  the  epidermis,  in  which  there  is  an  in- 
growth as  well  as  an  outgrowth  of  horny 
substance,  forming  circumscribed  epi- 
dermal thickenings,  chiefly  about  the  toes. 
Corns  may  be  hard  or  soft,  the  latter  be- 
ing situated  between  the  toes,  where  they 
become  softened  by  maceration.  Both 
forms  are  caused  by  intermittent  pressure 
and  friction.  Pressure  produces  pain  by 
driving  the  conical  mass  of  hardened  epi- 
thelium down  upon  the  sensitive  coriuni; 
constant  irritation  may  produce  inflam- 
mation  and   suppuration. 

Treatment.— The     use     of     well-fitting, 
comfortable     shoes     made     on     properly 
shaped  lasts  is  the  first   indication.     Tem- 
porary   relief    from    hard    corns    may    be 
obtained   by   the   use    of   felt   rings  which 
are   applied   over  the   corns,  allowing   the 
latter    to    project    through    the    opening. 
Prolonged  soaking  in  a  warm  solution  of 
sodium    carbonate    will    soften    the    corn, 
when  it  may  be  removed  by  gentle  scrap- 
ing  with    a    sharp    knife;    the    tender    sur- 
face left  may  be  protected  by  covering  it 
with  a  plaster-of  salicylic  acid  or  of  sali- 
cylic acid  with  cannabis  indica.     Another 
method   is    that    of    hardening   the    surface 
of   the    corn    by    applications    of   the   tinc- 
ture  of  iodine   or   silver  nitrate   at   night, 
removing  the  hardened  tissue   on   the   fol- 
lowing morning.     A   third   method   is   the 
use     of     the     salicylic-collodion     mixture: 
Salicylic  acid,  30  grains   (2  Gni.);  tincture 
of  iodine,  10  minims   (0.6  c.c);  extract  of 
cannabis  indica,  10  grains   (0.6  Gm.);  col- 
lodion,   4    drams     (15     c.c);    this     to    be 
painted    on    the    corn    night    and    morning 
for   several    days    and    then   removed   with 
the  corn,  by  soaking  in  hot  water.     Soft 
corns  are  best  treated  by  gentle  scraping 
to    remove    the    softened    epithelium,    the 
surface  being  then  protected  by  a  pad  of 
natural   wool    (as    it   is    clipped    from    the 
sheep),    or    of    absorbent    cotton,    having 
previously     dusted     the     surface     with     a 
powder  composed   of  equal   parts   of  zinc 
oxide    and    boric    acid.      When    corns    be- 
come   inflamed,    rest    and    warm,    moist, 
antiseptic   dressings  meet  the   indications. 
If    pus    has    formed    it    must    be    afforded 
an  exit  and   the  wound  treated   with   anti- 
septics,    iodoform,     anatol     or     europhen. 



Corns  should  never  be  cut  too  closely,  as 
erysipelas  and  gangrene  may  follow,  espe- 
cially in  the  aged. 

VERRUCA.— Verrucse  (condylomata; 
warts)  are  circumscribed  papillary  ex- 
crescences on  the  skin,  variable  in  color, 
smooth  at  the  summit,  or  studded  with 
moniliform  elevations  or  with  clusters 
of  minute,  pointed,  horny  filaments. 
They  may  be  single  or  multiple,  hard  or 
soft,  rounded,  flattened  or  acuminate. 
They  may  rapidly  attain  their  full  size, 
may  last  indefinitely  (/'.  pcrstans),  or 
spontaneously  disappear,  at  any  stage, 
and  are  not  contagious.  If  picked  or 
wounded,  warts  bleed  freely,  being  often 
very  vascular.  The  etiology  of  warts  is 

Treatment.  —  The  milder  applications 
consist  of  the  juice  of  the  milk-weed  (As- 
clcpias  coniuti  sen  Syriaca),  the  tincture 
of  iodine,  the  solution  of  iron  perchloride, 
moistened  powder  of  ammonium  chloride; 
stronger  applications  are  sublimate  col- 
lodion (30  grains  to  the  fluidram),  glacial 
acetic  acid  (best  of  acids,  as  it  leaves  no 
scar),  chromic  acid  and  fuming  nitric 
(nitroso-nitric)  acid.  Excision  (warts  on 
the  face  should  never  be  cauterized,  but 
excised)  or  curettage  if  the  warts  be 
soft,  is  the  quickest  method  of  removal; 
the  hypodermic  injection  of  cocaine  will 
lessen  or  prevent  the  pain,  and  the  ap- 
plication of  fuming  nitric  acid  to  the 
stump  or  base  will  restrain  the  hemor- 
rhage and  prevent  return.  A  10  per  cent. 
salicylic  acid  or  resorcin  ointment  is  slow 
but  effectual.  Electrolysis  is  efficient  but 
painful,  for  large  warts.  Ethyl  chloride 
spray,  liquid  air,  and  carbon  dioxide 
snow  are  efiicient.  Quicklime  rubbed  on 
the  hands  and  washed  off  in  an  hour  is 
effective  when  warts  are  numerous;  this 
should  be  done  twice  daily  and  con- 
tinued for  a  fortnight.  Intravenous  in- 
jections of  salvarsan  and  neosalvarsan 
have  been  used  successfully  when  warts 
were  numerous. 

The  internal  use  of  ><  pint  (250  c.c.)  of 
lime-water  daily  for  a  week  (Kennard)  and 
1  dram  (4  Gm.)  doses  of  Epsom  salt 
thrice  daily  (Ridley)  have  given  satisfac- 
tory results. 

Instead  of  cutting  or  the  use  of  caustics, 
Purdon   uses   an   India-rubber   finger-stall. 

if  the  warts  are  on  the  fingers,  or  an 
India-rubber  bandage,  if  they  are  on  the 
hands.  The  ruljl)er  exerts  gentle  pres- 
sure, while  the  wart  is  kept  moist  and 
macerated    from    retained    perspiration. 

Venereal  warts  may  be  washed  well 
with  bichloride  or  other  antiseptic  solu- 
tion, and  then  dusted  with  iodoform, 
calomel,   aristol,    or   europhen. 

wound  is  completely  healed,  a  cicatrix  or 
scar  occupies  its  place.  Normally,  two 
things  are  observed  in  a  scar:  its  contrac- 
tion and  the  gradual  perfecting  of  its 
tissues.  The  principal  changes  by'  which 
the  latter  is  accomplished  are  the  re- 
moval of  all  the  rudimental  textures;  the 
formatiori  of  elastic  tissue;  the  improve- 
ment of  fibrous  or  fibrocellular  tissue  of 
the  new  cuticle  till  they  are  almost,  but 
not  exactly,  like  those  of  natural  forma- 
tion; and  the  gradual  loosening  of  the 
scar,  so  that  it  may  move  easily  upon 
the    subjacent   tissues. 

Treatment. — Hypertrnphied  scars  may 
be  treated  by  multiple  incisions  and 
thiosinamine.  Tubb}-  uses  a  fine  and 
strong-backed  tenotomy  knife  and  makes 
a  large  number  of  incisions  in  the  scar 
tissue,  transversely  to  the  long  axis  of 
the  scar,  not  more  than  Yio  inch  apart, 
and  extending  both  into  the  subcutaneous 
fat  and  for  about  l^  inch  into  the  adja- 
cent healthy  skin.  Hemorrhage  is  stopped 
by  pressure  alone,  and  then  a  solution 
of  thiosinamine  is  thoroughly  rubbed  in. 
P^'rom  15  to  20  minims  (1  to  1.3  c.c.)  of 
the  solution  may  be  injected  at  one  time 
in  an  adult.  After  injection  the  part  is 
splinted    in    extreme    extension. 

Fibrolysin  plaster  applied  to  the  scar 
and  left  for  fourteen  days,  gave  excellent 

Excision  of  the  scar  and  repair  by 
plastic  operation  is  applicable  in  some 
cases.     See  also  page  176. 

KELOID.— Keloid  (cheloid;  kelis;  Ali- 
bert's  keloid;  spurious  keloid)  is  a  new 
growth  of  connective-tissue  formation 
having  its  seat  or  origin  in  scar  tissue 
and  resulting  in  the  formation  of  single 
or    multiple    tumors. 

Symptoms. — It  first  appears  as  a  pale- 
red  nodule  which  slowly  increases  in  size, 
assuming  a  more  or  less   oval  form,  with 



irregular,  well-defined,  radiating  projec- 
tions. From  its  resemblance  to  a  crab 
it  derives  its  name.  It  may  more  rarely 
assume  a  linear  form.  The  new  growth 
is  smooth,  firm,  elastic,  pinkish,  elevated, 
generally  devoid  of  hair,  usually  painless, 
but  sometimes  tender  when  touched  or 
subjected  to  pressure;  and  is  occasionally 
the  seat  of  the  most  intolerable  itching, 
which  no  external  application  seems  to 
relieve.  The  favorite  location  of  this 
growth  is  over  the  sternum,  but  it  may 
be  situated  on  the  mammae,  the  neck, 
arms,  and  ears.  In  rare  instances  the 
growth  may  become  inflamed  and  assume 
for  a  while  the  appearance  of  malignancy, 
which  appearance  disappears  usually  with 
the  spontaneous  decline  of  the  inflam- 
matory action.  The  development  of  the 
growth  may  be  slow  or  rapid,  until  a 
stationary  period  is  reached,  which  varies 
in  duration.  Spontaneous  disappearance 
of  the  growth  not  infrequently  occurs.  In 
some  cases  the  growth  becomes  painful, 
in  others  a  pigmentary  deposit  is  noticed. 
This  condition  was  first  described  by 
Alibert,  and  is  known  as  spurious  keloid 
to  distinguish  it  from  true  keloid,  which 
does    not    attack    scars     (Erichsen). 

Diagnosis. — AUbert's  keloid  is  dilifer- 
entiated  from  a  simple  cicatrix  by  its 
diiiference  in  consistence,  outline,  color, 
and  elevation,  and  by  its  increase  in  size. 
Its  points  of  difference  from  hyper- 
trophicd    scars    have    been    mentioned. 

Etiology  and  Pathology. — These  new 
growths  have  their  origin  at  the  seat  of 
some  injury  (sometimes  very  slight)  to 
the  skin,  as  the  cicatrices  of  burns,  flog- 
gings, cuts,  or  in  the  lobes  of  the  ears 
when  they  have  been  pierced  for  the 
accommodation  of  earrings.  They  are 
most  frequent  in  middle  life  and  in  the 
colored  race.  The  growth  consists  of 
dense  fibrous  tissue,  which  involves  the 
corium  and  extends  in  the  direction  of 
the  connective  tissue  about  the  blood- 

Prognosis. — The  prognosis  is  not  gen- 
erally very  favorable,  although  the  growths 
may  sometimes  disappear  spontaneously. 
The  stationary  period  may  extend  over 
years  or  during  life.  Occasionally,  after 
a  stationary  period  of  variable  duration, 
an    increase   in    size    takes    place. 

Treatment. — The  treatment  of  these 
new  growths  is  not  very  satisfactory. 
The  application  of  anodyne  liniments  or 
hypodermic  injections  of  morphine  will 
generally  relieve  pain  when  present.  The 
administration  of  large  doses  of  liquor 
potassae  will  often  relieve  the  pruritus. 
Removal  by  knife  or  caustics  should  not 
be  attempted  while  the  growth  is  increas- 
ing. Fused  caustic  potash  is  recom- 
mended as  best,  if  any  caustic  is  used. 
Multiple  electrolytic  puncture  and  re- 
peated scarification,  making  numerous 
parallel  linear  cuts  crossed  at  various 
angles  by  other  parallel  linear  cuts,  have 
been  suggested  with  the  idea  of  replacing 
the   diseased   scar  by  a  healthy  one. 

Sodium  salicylate  taken  internally  (20 
to  30  grains— 1.3  to  2  Gm. — three  or  four 
times  daily)  has  a  marked  effect  in  the 
resolution  and  absorption  of  keloid.  In- 
jections of  fibrolysin  (35  minims — 2.3  c.c.) 
made  daily  or  even  once  a  week  has 
caused  the  disappearance  of  keloid. 

Radium  has  proven  highly  effectual  both 
for  keloids,  excessive  scarring,  and  deep 
fibrous  adhesions.  All  cases  of  keloid  re- 
ported on  by  F.  C.  Harrison  (1918) 
showed  disappearance  or  marked  improve- 
ment under  radium.  Weil  exposed  keloid 
to  very  hard  X-rays.  Lesieur  reported 
satisfactory  results  in  100  cases  from  in- 
jections of  creosote  in  sterile  olive  oil, 
1:15;  2  drops  to  80  minims  (5  c.c.)  are 
injected  under  the  keloid  at  each   sitting. 

SCARS. — The  cicatrix  of  a  burn  or  other 
extensive  scar  may  undergo  malignant 
degeneration  many  years  after  its  forma- 
tion. Erichsen  removed  a  large  cancroid 
growth  from  a  cicatrix  of  a  burn,  on  the 
forearm  of  a  woman,  seventy  years  after 
the  receipt  of  the  injury,  which  happened 
in    childhood. 


DEFINITION.— A  burn  is  a  high 
grade  of  acute  inflammation,  following 
the  direct  or  indirect  application  of  dry 
or  moist  heat  to  a  portion  of  the  cu- 
taneous   or    mucous    surfaces. 

VARIETIES.— For  ease  of  comprehen- 
sion burns  have  been  separated  into 
grades   according   to   their    severity. 

A  temperature,  slightly  increased  above 
the    normal    (as,    for    instance,    100°    F. — 



37.8°  C),  produces  only  a  slight  hyper- 
emia (first  degree:  dermatitis  ambus- 
tionis  erythematosa),  which  may  dis- 
appear shortly  after  breaking  the  contact, 
while  a  rise  of  150°  F.  (65.6°  C.)  will 
cause  some  appearance  of  vesicles  and 
bull?e  (second  degree:  dermatitis  am- 
bustionis  vesiculosa  et  bullosa)  and  de- 
struction of  the  epidermis,  the  effect  of 
which  is  not  relieved  for  days  after  the 
removal  of  the  burning  substance,  and 
yet,  on  the  other  hand,  heat  at  the  boil- 
ing point  of  water  (212°  F.— 100°  C.) 
may  cause  a  complete  carbonization  of 
the  part,  resulting  in  the  formation  of 
eschars  varying  in  color  from  a  yellow 
up  to  a  dark  brown  or  black  or,  in  other 
words,  the  production  of  gangrene  (third 
degree:  dermatitis  ambustionis  escharot- 
ica  seu  gangrenosa). 

SYMPTOMS.— The  effects  of  a  burn 
upon  the  body  structure  are  both  local 
and  constitutional.  The  former  often 
results  in  great  disfiguration  or  destruc- 
tion of  tissue,  while  the  latter  depresses 
the  vital  forces  or  terminates  in  death. 

Local  Effects. — In  burns  of  the  first 
degree  the  appearances  produced  are  su- 
perficial. There  will  be  observed  a  dis- 
tinct hyperemia  with  redness  of  varying 
intensity  from  the  slightest  blush  up  to  a 
pinkish  red  or  brownish  red.  This  may 
or  may  not  be  entirely  effaced  by  pres- 
sure. This  type  of  burn  is  produced  by 
indirect  contact  with  the  flame  of  a 
lighted  match,  proximity  to  a  heated 
metal,  escaping  steam,  and  the  actinic 
rays  of  the  sun.  With  or  without  treat- 
ment the  effect  of  burning  to  this  extent 
maj'  disappear  shorlj'  after  removing  the 
exciting   cause. 

In  burns  of  the  second  degree  the  in- 
flammation, while  yet  superficial,  may 
still  occupy  the  entire  epidermis.  In 
some  cases  the  upper  layers  alone  of  the 
cuticle  may  be  destroyed,  while  vesicles 
or  bullae  may  be  observed  over  the  af- 
fected surface.  In  still  other  cases  the 
corium  is  stripped  entirely  of  its  epi- 
dermal covering  or  particles  of  the  mem- 
brane may  be  rolled  into  whitish  masses 
over  its  exposed  surface.  These  vesicles 
or  bullae  may  be  produced  directly  by  the 
contact  of  the  heated  article  or  indirectly 
by    the    consequent    inflammation.      They 

may  retain  their  contents  or,  owing  to 
the  increased  flow  of  serum,  their  walls, 
becoming  thin  and  losing  their  elasticity, 
rupture,  thus  allowing  the  escape  of  a 
continual  discharge  over  the  denuded  sur- 
face. The  true  skin,  which  is  exposed 
either  entirely  or  at  points,  shows  a 
highly  reddened  surface,  over  which  this 
continual  exudation  may  be  observed. 
In  this  type  of  condition  actual  contact 
with  the  heated  substance  takes  place 
either  in  shorter  or  longer  durations. 
Such  articles  as  heated  iron,  transient  or 
lengthened  action  of  flames,  aiid  boiling 
liquids  may  be  the  exciting  agent.  The 
effects  of  this  form  of  burn  do  not  al- 
ways show  to  what  extent  they  have 
progressed  immediately  upon  the  removal 
of  the  cause,  because  of  the  systemic  con- 
ditions which  may  be  induced.  Pain  is 
always  present  to  a  minor  or  major 

Resolution  takes  place  through  coagu- 
lation of  the  serous  discharge,  which 
occupies  the  involved  area  as  a  fibro- 
albuminous  covering  beneath  which  the 
new  skin  is  allowed  to  form. 

In  the  burns  of  the  third  degree  the 
inflammation  or  destruction  may  be  su- 
perficial, extending  over  considerable  area, 
or  deep,  affecting  the  subcutaneoos  tis- 
sues,  muscles,  and   even   bones. 

Resolution  takes  place  in  the  uncovered 
variet}'  in  the  same  manner  as  described 
under  the  foregoing  degree,  while  in  the 
covered  variety  granulations  spring  up 
beneath  the  charred  remains  which,  after 
a  time,  desiccate  and  fall  off,  exposing  a 
similar  surface  to  that  of  the  second 

In  the  deeper  form  of  burn  the  extent 
of  surface  involved  may  be  small  or 
large,  but  may  dip  down  to  varying 
depths.  The  amount  of  charring  will  usu- 
ally be  very  great  and  will  lie  about  in 
masses  over  the  burned  surface,  thus 
preventing  a  view  of  the  destruction  be- 
neath. Resolution  even  in  the  milder 
cases  is  slow,  and  before  such  happens 
surgical  interference  may  be  demanded. 
The  cause  which  brings  about  this  form 
of  burning  is  usually  dry  heat  (flames  or 
contact  with  electric  wires);  it  entails 
much  greater  destruction  than  will  moist 
heat.      The     effect    upon    the     system    is 



alarming,  and  shock  may  carry  off  the 
person   before  relief  can  even  be  attempted. 

Electric  and  X-ray  Burns. — Burns  from 
electricity  may  be  observed  in  all  the 
varieties  mentioned  above.  They  may 
follow^  direct  or  indirect  contact.  Exam- 
ples of  direct  contact  are  observed  after 
handling  live  (charged)  wires,  and  may 
be  found  to  destroy  all  parts  with  which 
it  comes  into  touch,  or  life  even  may  be 
the  forfeit.  Such  burns  resemble  moist 
gangrene  or  severe  frost-bite.  The  pain 
is  often  very  severe  and  the  healing  pro- 
cess is  much  slower  than  in  the  case  of 
ordinary  burns. 

A  most  recent  form  of  burning  of  the 
skin  from  the  indirect  contact  of  elec- 
tricity is  by  the  X-ray  apparatus.  Close 
proximity  to  the  ray  by  either  covered  or 
uncovered  parts  result  either  in  a  super- 
ficial or  deep  inflammation  of  the  skin.  It 
may  be  observed  a  few  hours  after  ex- 
posure to  the  rays  or  may  be  delayed  for 
several  weeks.  This  form  of  burning  at- 
tacks the  skin  alone  in  some  instances, 
while  in  others  the  deeper  structures,  as 
the  muscles,  tendons,  nerves,  and  bones 
(periostitis  and  ostitis  resulting)  are  in- 
volved. The  effects  may  remain  for  days, 
weeks,  or  even  months  after  the  applica- 
tion. The  X-ray  burns  are  supposed  by 
some  to  be  produced  by  the  action  of  the 
ray  or  by  particles  of  aluminium  or 
platinum  reaching  and  being  deposited  in 
the  tissues  by  others,  and  by  others  to  be 
the  result  of  an  interference  with  the 
nutrition  of  the  part  by  the  induced 
static    charges. 

The  patient  may  be  absolutely  pro- 
tected from  the  harmful  effects  of  this 
static  charge  by  the  interposition  between 
the  tube  and  the  patient  of  a  grounded 
sheet  of  conducting  material  that  is 
readily  penetrable  by  the  X-ray,  a  thin 
sheet  of  aluminium  or  gold-leaf  spread 
upon  cardboard  making  an  effectual  protec- 
tive shield. 

Burns  of  Mucous  Surfaces. — The  mu- 
cous surfaces  may  be  affected  by  the 
inhalation  of  flames,  vapors  (volatile  or 
boiling  acids),  boiling  liquids  (water, 
slacked  lime),  and  by  certain  substances 
acting  directly,  such  as  ammonia  and 
sulphuric  and  hydrochloric  acids.  The 
mouth,     pharynx,      larynx,     bronchi,     and 

the  esophagus,  as  well  as  the  stomach, 
share  in  the  attack.  The  eye  often,  from 
its  exposed  position,  is  the  seat  of  burn. 
Conjunctivitis  often  results  from  irritants 
coming  into  direct  contact  with  the  eye, 
and  if  the  exciting  agent  is  not  soon  re- 
moved great  destruction  of  substance  or 
sight  may  be  the  result. 

Constitutional  Effects.— The  effects  of 
burns  of  the  first  degree  upon  the  system 
are  generally  slight  and  are  limited  to 
pain  which  disappears  shortly  after  the 
removal  of  the  exciting  agent,  but  often 
may  last  for  several  hours. 

In  burns  of  the  second  degree  the  pain 
accompanies  the  phenomena  not  alone  for 
hours  and  days,  but  often  for  weeks  and 
even  months.  The  shock  may  be  of  a 
transient  character  or  of  an  alarming  in- 
tensity. It  may  be  encountered  at  the 
time  of  accident  or  be  delayed  for  peri- 
ods varying  from  hours  to  days  there- 
after. When  small  areas  are  involved, 
the  depression  may  soon  be  relieved,  but 
when  one-fourth  or  one-third  of  the 
body  is   attacked   death   may  intervene. 

Burns  of  the  third  degree  may  be  so 
severe  that  death  intervenes  before  pain 
has  time  to  appear.  Shock  at  this  stage 
is  therefore  observed  early  and  of  the 
worst  character.  Early  mortality  is  gen- 
erally due  to  the  shock,  while  late  mor- 
tality usually  occurs  during  the  stage  of 
suppuration.  Vomiting  is  often  observed 
in  both  the  second  and  third  degrees. 

Children  suffer  more  from  burns  than 
do  adults,  and  women  more  severely  than 
men.  The  temperature  is  not  affected  by 
burns  of  the  first  degree,  but  is  a  marked 
symptom  in  those  of  the  second  and  third. 
At  the  time  of  the  accident  it  may  de- 
cline from  1  to  3  degrees  below  the 
normal— to  97°  F.  (36.1°  C.)  or  even  95° 
F.  (34.9°  C.)  and  remain  at  that  point 
until  reaction  begins,  which  is  in  about 
thirty-six  or  forty-eight  hours,  when  it 
rises  during  the  next  twelve  to  eighteen 
hours  to  104°  F.  (40°  C.)  or  106°  F. 
(41.1°  C.)  or  more,  at  which  point  it  re- 
mains for  a  period  of  eight  to  ten  days 
(possibly  rising  and  lowering  at  irregular 
intervals),  when  granulations,  now  in  fair 
formation,  act  as  a  retarding  agent. 

Vannini  reported  cases  of  six  burns  of 
varying    degrees    of    severity,    in     all     of 



which  glycosuria  was  present.  The  gly- 
cosuria was,  as  a  rule,  transitory,  and 
was,  in  all  probability,  toxic  in  its  origin, 
and  connected  with  hyperglycemia.  When 
sugar  is  present  after  burns,  the  diet  of 
the  patient  should  be  modified. 

COMPLICATIONS.— The    after-effects 

of  burns  may  be  concentrated  upon  the 
viscera  (neural,  thoracic,  and  ventral  cavi- 
ties) or  directly  upon  the  part  affected 
(cicatrices,  contractions,  and  fractures  of 
bone).  Burns  of  the  first  degree  remain 
uncomplicated,  while  those  of  the  second 
and  third  present  many  variations.  The 
meninges  (arachnitis  following  burns  of 
the  head),  as  well  as  the  brain  proper, 
may  become  congested  or  even  highly 
inflamed,  the  sufferer  presenting  all  the 
symptoms  of  restlessness  and  delirium 
ending  either  in  convulsions  or  coma. 
Tetanus  is  an  early  complication  ob- 
served. Bronchitis  and  pneumonia  often 
result  either  from  inhalations  or  indi- 
rectly from  surface  burns.  Congestion  in 
the  kidney  has  been  noted,  with  resulting 
albuminuria  or  hemoglobinuria,  while  in 
many  cases  the  urine  becomes  exceedingly 
scanty.  Autopsies  have  shown  rupture  of 
the  diaphragm  and  stomach,  accompanied 
by  contraction  of  the  bladder.  Amyloid 
degeneration  in  the  viscera  has  been  noted 
after  prolonged  suppuration.  Inflamma- 
tion of  the  gastrointestinal  tract  with 
the  formation  of  an  ulcer  (usually  one, 
but  more  rarely  several)  of  the  duodenum 
(at  its  pyloric  end)  frequently  occurs. 
This  ulceration  may  begin  early  (four  or 
five  days)  or  it  may  be  delayed  for 
weeks,  although  without  the  appearance 
of  rectal  hemorrhage  or  perforation,  with 
consequent  peritonitis,  we  have  no  means 
of  determining  its  presence.  At  times 
this  inflammation  extends  to  the  colon 
and  causes  diarrhea.  Burns  affecting 
either  the  chest  or  abdomen  are  the  in- 
ducing cause,  although  severe  burns  at 
other  points  may  produce  them.  Sep- 
ticemia, pj^emia,  or  erysipelas  (the  strep- 
tococci being  found  after  death  in  the 
blood)    may   be   the  fatal   ending. 

The  theories  of  the  causes  of  death  from 
burns   may    be    divided   into   four   classes: 

(1)  death    from    shock    or    extreme    pain; 

(2)  embolism,    thrombosis,    and    destruc- 
tion   of    the    blood-elements;     (3)    pyemic 

infection  through  the  burned  surface; 
(4)  poisons  formed  by  the  action  of  heat 
on  the  tissues,  or  autointoxication  from 
deficient  excretion  by  the  skin.  By  ex- 
perimenting upon  dogs  and  rabbits  it  is 
personally  claimed  that  the  intoxication 
theory  is  the   correct  one. 

The  attempt  of  nature  to  restore  a  cov- 
ering for  these  denuded  tissues  often  re- 
sults unwisely.  Vicious  scars,  adhesions 
of  contiguous  parts  (causing  webbed  fin- 
gers, the  arm  being  attached  to  the  side 
by  granulations),  and  deformities  may  be 
encountered.  Calcareous  degeneration  or 
even  epithelioma  may  attack  the  scars. 
Pressure  upon  the  terminals  of  the  nerves 
may  either  cause  neuralgia  or  spasm  of 
the  glottis,  which  may  demand  surgical 
interference  for  its  removal.  Finally, 
keloidal  tumors  may  be  observed  as  a 
consequence  of  vicious  scarring.  All  of 
the  scar  may  not  be  affected  with  keloid, 
as,  for  instance,  one  end  may  show  the 
prolongations,  while  the  other  resembles 
ordinary  cicatrices.  The  contractions  of 
the  skin  after  scarring  may  produce  great 
deformit}^  and  the  hand  may  be  drawn 
backward  upon  the  arm  or  talipes  cal- 
caneus may  result  or  other  disfigurations 
too  numerous  to  mention  may  be  shown. 
Exposure  of  joints  has  taken  place  by 
ankylosis.  Bones  have  been  fractured 
from  loss  of  substance  (cooking  of  the 

DIAGNOSIS.— Ordinarily  the  recog- 
nition of  burns  is  not  a  dithcult  task,  al- 
though the  differentiation  of  the  varieties, 
especially  of  the  second  and  third  degrees, 
may  demand  careful  examination.  Burn- 
ing flesh  with  destruction  of  its  particles^, 
exposure  of  the  underlying  tissues  (mus- 
cles, bones,  etc.),  will  be  a  train  of  symp- 
toms not  to  be  controverted.  The  dif- 
ference between  burns  and  scalds  often 
may  occasion  difficulty,  but  the  fact  of 
the  greater  and  deeper  destruction  of  the 
former  with  the  more  superficial  charac- 
ter af  the  latter  will  generally  be  suf- 
ficient. The  loss  of  hair  follows  the  for- 
mer because  of  this  deep  destruction  of 
the  hair-follicle  and  papilla. 

BURNS. — In  cases  where  the  persons 
have  been  alive  when  they  were  exposed 
to  the  fire,  soot  is  found  in  the  ramifica- 



tions  of  the  trachea  and  bronchi.  If  the 
red  blood-corpuscles  are  found  disinte- 
grated and  disfigured  throughout,  then 
this  is  a  further  sign  of  a  person  having 
been   burnt  while   alive. 

The  presence  of  carbon  monoxide  in 
the  blood  is  an  almost  positive  proof  that 
the  person  during  life  was  not  exposed  to 
the  influence  of  fire. 

PROGNOSIS.— The  termination  of  this 
class  of  injuries  is  often  of  serious  import, 
especially  when  medicolegal  questions 
arise.  This  should  be  determined  by  the 
several  factors  which  arise  in  each  case. 
Consideration  must  be  given  to  indi- 
viduality of  the  sufferer,  both  his  age  and 
constitutional  acquirements;  the  extent  of 
the  burn,  both  as  to  surface  and  depth  in- 
volved; the  location  of  the  injury,  and  the 
nature  of  the  exciting  medium.  The  ef- 
fects upon  strong,  robust  subjects  are 
not  so  marked  as  upon  those  of  weaker 
constitutions,  and  while  the  same  degree 
or  extent  of  burn  will  soon  be  recovered 
from  by  the  former,  the  most  dire  results 
may  follow  in  the  latter  persons.  Thus  it 
may  be  noticed  that  burns  among  ma- 
chinists, glass-blowers,  plumbers,  and 
foundrymen  will  not  be  so  serious  as 
would  the  same  degree  or  extent  among 
clerks  or  those  engaged  in  gentlemanly 
pursuits.  Colored  persons  suffer  less  se- 
verely than  do  the  white.  Females,  on 
account  of  more  delicate  systems,  are  less 
able  to  resist  shock  than  are  the  males. 
Middle  life  is  not  so  severely  affected  as 
are  children  or  aged  people.  Some  per- 
sons may  be  able  to  resist  the  shock  only 
to  be  carried  off  by  the  complications  that 

Surface  involvement  seems  to  exert  a 
greater  depression  or  fatality  than  does 
depth  of  tissue.  A  burn,  even  of  the  first 
degree,  which  occupies  an  extended  area 
and  those  of  the  second  may  terminate 
fatally  if  one-fourth  or  one-third  of  the 
superficial  parts  are  involved;  a  fatal  is- 
sue may  also  occur  in  burns  occupying 
one-half  of  the  body  surface.  A  burn  of 
the  second  degree  which  occupies  only  a 
limited  extent  of  surface,  but  which  de- 
stroys the  epidermis  entire,  may  end  in 
recovery,  while  those  of  the  third  may, 
through  their  deep  involvement,  produce 
complications   with    which    we    are    unable 

to  combat.  Burns  occupying  the  abdo- 
men give  the  highest  mortality,  while 
those  of  the  thorax  are  only  second  to  a 
slightly  minor  extent;  but  those  of  the 
head,  neck,  and  limbs  prove  fatal  in 
many  instances.  Of  twenty-six  cases  seen 
by  Sajous  after  a  boiler  explosion  on  the 
Lake  of  Geneva,  in  1892,  twenty-two  died 
within  a  few  hours  after  the  accident,  al- 
though, with  few  exceptions,  the  scalds, 
though  involving  the  greater  part  of  the 
body,  did  not  reach  beyond  the  epidermic 
layer,  excepting  over  the  face  and  hands. 

The  length  of  time  required  for  the 
partial  or  complete  reparation  of  the  sur- 
face may  be  an  important  question  in 
inedicolegal  cases.  This  can  only  be  gov- 
erned by  the  type  of  injury,  the  length  of 
contact  of  the  exciting  agent,  the  nature 
of  the  affected  person,  and  the  general 
aspects   of  the  case  in   question. 

TREATMENT.  — Constitutional.  —  The 
constitutional  treatment  is  to  be  directed 
toward  the  relief  of  pain,  the  restoration 
of  the  depressed  vitality  at  the  time 
of  accident, — i.e.,  sustaining  the  system 
throughout  the  entire  restorative  process. 
Pain  is  best  relieved  by  opium,  or  its  al- 
kaloid, morphine  (preferably  by  hypoder- 
mic injection),  because  these  agents  have 
little,  if  any,  depressing  action  upon  the 
cardiac  functions.  The  dose  required  will 
be  much  greater  than  ordinarily  used,  be- 
cause of  the  sudden  character  and  great 
amount  of  depression  in  these  injuries. 

Vitality  must  be  restored  as  quickly  as 
possible,  and  the  use  of  ammonia  (prefer- 
ably carbonate),  strychnine,  and  caffeine 
(because  of  their  stimulating  effect  upon 
the  cardiac  muscle) ;  hot  drinks,  such  as 
milk  and  tea;  alcohol  in  the  form  of 
whisky  or  brandy,  and  the  production  of 
local  or  generalized  sweating.  A  most 
desirable  plan  of  restoring  heat  is  by 
using  hot-water  bottles  placed  at  regular 
points  so  as  to  diffuse  its  effects.  Other 
means,  as,  for  instance,  covering  the  body 
with  a  sheet  and  conveying  heat  through 
a  pipe  or  by  placing  heated  bricks  beneath 
this  covering.  To  keep  the  sufferer  fairly 
comfortable  during  the  local  treatment 
stimulation  must  be  kept  up,  care  being 
taken  not  to  produce  overactivity  and  thus 
allow  reaction  to  prove  as  deleterious  as 
the  effect  of  the  burn. 



Tlic  functions  of  the  body  must  be 
regulated,  the  bowels  being  kept  free  or 
confined,  according  to  the  conditions  pres- 
ent: the  action  of  the  kidneys  should  be 
watched.  In  some  cases  it  may  be  wise 
to  anesthetize  the  patient  during  the  first 
few  hours  immediately  following  the  burn, 
and  especiall}^  during  the  first  dressings 
of  aggravated  cases. 

Local. — The  local  treatment  is  to  be 
directed  toward  the  limitation  of  the  re- 
sulting inflammation,  the  prevention  of 
septic  infection,  assisting  the  normal 
elimination  of  the  eschar,  the  develop- 
ment of  granulations,  and  limitation  of 
the    deformity. 

In  burns  of  the  first  degree  little  or 
no  treatment  may  be  demanded.  In  the 
more  aggravated  cases  of  this  t3'pe  the 
application  of  home  measures,  such  as 
sodium  bicarbonate,  the  white  of  egg  and 
sweet  oil  (equal  parts),  lead-water  and 
laudanum,  and  the  various  hot  or  cold 
means  generally  at  the  disposal  of 

Burns  of  the  second  and  third  degrees 
must  be  more  strenuously  treated.  It  is 
often  a  difficult  problem  to  know  which 
is  the  more  soothing  application  to  be 
advised  and  from  which  we  may  get  the 
better  result.  In  one  case  hot  applica- 
tions, in  another  cold;  in  some  wet,  and  in 
others  dry  measures  are  to  be  given. 
The  vesicles,  if  numerous,  should  be  un- 
touched; but  if  onl}'^  a  few,  they  are  best 

Prof.  S.  D.  Gross  was  wont,  in  many 
mild  and  severe  cases,  to  use  ordinarj- 
white-lead  paint;  this  is  a  remarkably  ef- 
ficacious measure.  Mere  painting  of  the 
burn,  as  if  it  were  an  article  of  furniture, 
etc.,  causes  immediate  cessation  of  the  pain. 

The  use  of  carbolized  petrolatum  (3  to 
6  per  cent.),  watery  solutions  of  carbolic 
acid  (4  per  cent.),  bismuth  subnitrate 
(Vi  to  1  dram — 2  to  4  Gm. — to  1  ounce — 
30  Gm. — of  ointment  of  zinc  oxide  or 
petrolatum),  boric  acid  (either  in  watery 
saturated  solutions  or  ointments  of  either 
zinc  oxide  or  petrolatum  in  strengths 
varA'ing  from  6  to  25  per  cent.),  sodium 
bicarbonate  in  almost  full  strength  (in 
ointment  or  watery  solutions),  and  starch 
in  varying  proportions  will  usually"  be 
found  very  efficacious. 

Turpentine,  where  granulations  are  slug- 
gish, will  give  excellent  results  used 
cither  in  full  or  diluted  strength,  giving 
care  not  to  produce  too  much  stimulation. 

When  there  are  large  vesicles,  these  are 
opened  on  the  second  or  third  day.  It  is 
best  to  keep  the  turpentine  off  the  healthy 
skin  if  possible  to  avoid  local  irritation. 

Surgery  of  this  day  has  placed  many 
excellent  antiseptics  at  our  disposal,  and 
there  is  no  better  application  than  mer- 
cury bichloride  in  the  proportion  of  1  to 
lOUO  parts  of  water  and  kept  in  constant 
contact,  the  dressings  being  made  without 
removing  the  former  cloths. 

Ichthyol  in  watery  solutions  (1  to  8, 
or  stronger,  or  in  glycerin,  similar 
strength),  or  even  in  from  12  to  36  per 
cent,  ointment  with  zinc  oxide  or  petrola- 
tum and  the  iodine  derivatives,  such  as 
iodol,  aristol,  europhen  (given  preferably 
in  ointment  3  to  6  per  cent,  with  petrola- 
tum or  lard)  are  reliable  measures. 

Thiol  has  been  found  useful  for  all  de- 
grees of  burn;  it  allaj-s  pain  verj-  rapidly 
and  arrests  cutaneous  hyperemia,  in  this 
manner  tending  to  prevent  ulceration  and 

Aristol  is  another  valuable  agent  in 
burns  of  the  second  and  third  degrees, 
and  has  been  found  strikingly  effective 
where  other  remedies   have  failed. 

It  may  be  used  in  the  form  of  powder 
or  mixed  with  oil  or  petrolatum.  The 
application  of  aristol  powder  directly  to 
the  wound  at  the  beginning  hinders  the 
dressing  from  soaking  up  the  secretion; 
when  the  latter  has  diminished,  however, 
aristol  may  be  applied  either  alone  or  in 
a  10  per  cent,  ointment  with  olive  oil, 
petrolatum,  and  lanolin. 

Many  authoritative  surgeons  have  lauded 
picric  acid  used  in  saturated  solutions 
with  water  (increasing  the  solubility  by 
means  of  the  addition  of  1  ounce — 30 
c.c. — of  alcohol,  as  the  acid  is  soluble  to 
the  extent  of  only  2  drams — 8  Gm. — to 
the  quart — liter — of  water).  It  is  par- 
ticularly useful  for  the  relief  of  pain 
and  it  greatly  assists  the  formation  of 
granulations.    . 

The  combination  of  picric  and  citric 
acids,  which  Esliach  devised  for  the  de- 
tection of  albumin,  is  more  effective  than 
the  picric  acid  alone,  in  burns   of  the  sec- 

SKIN,    SURGICAL  DISEASES   OF.                                        175 

ond  degree.     Esbach's  solution  consists  of  Granulations   may   often    be   assisted   by 

10  parts    of   picric   acid,   20   of   citric   acid,  powders  of  acetanilide  in  full  strength,  or 

and    KKX)   of    water.     The   bullae  and   vesi-  with  equal  parts  of  boric  acid,  dusted  over 

cles  should,  be  opened  with  a  clean  blade  the  area,  or  by  means  of  iodol,  europhen 

and  the  fluid  applied  freely.     Repeated  ap-  or  aristol  (3  to  12  per  cent.)  with  powdered 

plication   of   tincture   of  ferric   chloride   is  starch  or  in   ointment.     Scarlet  red  in   10 

another    useful    form    of    treatment.      Cal-  per  cent,   solution  may   also  be  used. 

cined    magnesia,    in    a    paste    made    with  Limitation  of  deformity  is  often  a  seri- 

water,   is  serviceable  in   l)urns   of  the  first  ous  problem  though  in  some  measure  ob- 

and     second     degrees.      Iodoform,     as    an  viated  by  paraffin  treatment.     Splints  may 

analgesic    and    antiseptic,    may    be    left    in  be  utilized  and  they  should  be  kept  applied 

situ    for    some    time.      Potassium    nitrate  for  some  time  after  the  parts  have  healed 

solution   is   useful,   chiefly   as   refrigerant.  because   of   the   inherent   tendency   to   the 

The  paraffin  treatment  of   severe   burns  contraction   for  long  periods,   even  years, 

constitutes  a  distinct  advance  over  the  pro-  after  an  apparent  cure.     Bandages  are  to 

cedures    previously    in    general    use.      Be-  be    kept    continuously    applied    to    prevent 

sides    forming   a    painless    dressing,   which  contiguous    surfaces    from    becoming    ag- 

is    easy    of    application    and    removal,    and  glutinated.      Massage    must   be   advised    at 

does  not  favor  infection,  it  results  in  more  the  very  earliest  moment  so  as  to  restore 

rapid   healing,   and   leaves   a   smooth,   soft,  the  pliability  of  the  part  and  prevent  anky- 

pliable  scar,  with  little  or  no  tendency  to  losis  when  a  joint  is  involved.     Even  with 

contracture    and    deformity.      Either    am-  all    the   measures    that   we   can   adopt   the 

brine  or  one  of  the  numerous  substitutes  loss    of    skin-tissue    may    be    so    extensive 

for    it    may    be    used.      The    burn    is    first  that  skin-grafting  will  be  the  only  means 

washed  with  sterile  water,  saline  solution,  with    which    we    can    hope    to    restore   the 

or  boric  acid  solution;  it  may  be  sprayed  integrity   of   the  part.     The  relief   of  cica- 

with  a  3  to  5  per  cent,  solution  of  dichlo-  trices   or   contractions,  ankylosis,   or  pres- 

ramine-T,  followed,  if  necessary,  by  liquid  sure  upon   the  nerve-filaments   sometimes 

petrolatum  to  allay  pain.     It  is  then  dried  requires    the    most    energetic    surgical    in- 

with  sterile  gauze  or  an  electric  dryer,  and  terference. 

the  paraffin  preparation  applied  with  a  TREATMENT  OF  ELECTRICAL 
broad  camel's  hair  brush  or  special  sprav  BURNS. — Elder  advises  that  the  part  sub- 
apparatus.  Shere  recommends  the  follow-  jected  to  the  burn  be  immersed  and  kept  in 
ing  mixture: ^  warm   carbolic-lotion  bath,   1   per   cent., 

,,„  .               ,.                                       ic  ^,,„,^^  taking  precautions   against   the   possibility 

White  vaseline   15  ounces.  ,    ,,"'   ^                        %               i          u 

,...,,,  ^                                    9  ^,,„ooc  of    the    occurrence    of    secondary    hemor- 

Liquid  petrolatum   Z  ounces.  -' 

Oil  of  euealyptus  1  ounce.  --hage.    If  secondary  hemorrhage  occur   or 

Paraffin  (melt.  pt.  42.7°  C.)   ..   16  ounces.  ^hen    a    definite   Ime^  of    demarcation    has 

formed,    the   necrosed   tissue  must  be  re- 

Iv lute  uax.  J        T                                            ,    ,.         . 

„.     ,             J.          ,        ,                 T/  ^,,„„„  moved.      In    many     cases    amputation    is 

Pix  burgundica,  of  each  ^  ounce.  ,..,        ,-r,           i,,       .u 

necessary,  but  the  skin-Haps  should  not  be 

For    the    first    few    days,    1    dram    each    ot  closed,  because  large  masses  of  muscle  are 

thymol,  iodide   and  menthol  are   added  to  gm-e   to    slough    away    subsequently.      The 

allay  infection  and  pain;  later,  >2  to  1  per  wound    should    be    allowed    to    granulate, 

cent,  of  scarlet  red,  and  when  epithclializa-  and   subsequently  be  skin-grafted.     Imme- 

tion    is    nearly    complete,   bismuth    subgal-  diately   after   the   burn    hypodermic   injec- 

late,    1    to    10.      A   thin   layer   of    cotton    is  tions    of    morphine    (%    grain — 0.01    Gm.) 

placed    over    the    first   layer   of   paraffin,   a  and  strychnine  (V.s(»  grain — 0.002  Gm.)  may 

second    paraffin    coating    applied,    and    the  j^g  given  alternately.     To  lessen  the  oft'en- 

dressing  completed  with  cotton  and  band-  give   odor   the    1    per   cent,    carbolic   lotion 

age.      Redressing    is    done    daily    at    first,  niay  be  replaced  by  a  bath  of   1   in   10,000 

later   on   alternate   days.  mercury     bichloride.       In     addition,     mor- 

The    lethal    tendency    of    burns    is    best  phine,  phenacetin,  caffeine,  chloral  hydrate, 

met  by  removing  the  necrosed  tissues  and  and   potassium  bromide   may   be  adminis- 

infusion  of  saline  solution,  repeated  daily.  tered  together. 



Immobilization  of  the  part  aiul  protec- 
tion with  sterile  gauze  arc  necessary, 
and,  if  the  hum  is  extensive,  skin-grafting. 


Scars,  even  when  adherent  to  hones,  j)ain- 
ful  thickenings  following  injuries  or  hums, 
or  of  the  tendons,  are  favorably  influenced 
by  X-rays.  Grace  (Am.  Jour,  of  Pllectr. 
and  Radiol.,  Oct.,  1919)  uses  a  filter  of 
1  mm.  of  aluminium  for  the  superficial 
cases  and  of  2  mm.  for  the  deeper.  The 
Palzsche  method,  a  salve  composed  of 
pepsin,  hydrochloric  acid,  and  phenic  acid, 
each  1  per  cent.,  rubbed  into  the  scar  twice 
daily,  is  also  effective  according  to  Schues- 
sler  (Miiench.  med.  Woch.,  Ixviii,  72,  1921). 
Moist  compresses  are  applied  at  night. 

C,  W.  and  S. 

SODIUM* — Sodium,  or  natrium,  is 
a  light,  soft,  ductile,  malleable  metal, 
of  silver-white  luster  when  freshly  cut, 
and  of  dull-gray  color  when  oxidized 
by  air.  Like  potassium,  it  has  a  strong 
afifinity  for  oxygen,  and  must  be  kept 
immersed  in  a  liquid  free  from  oxy- 
gen, such  as  benzene  or  naphtha. 
Thrown  upon  water,  it  burns  with  a 
bright  yellow  flame,  imiting  with  the 
oxygen  of  some  of  the  water  and 
forming  in  the  remainder  a  solution  of 
sodium  hydroxide.  The  pure  metal  is 
not  used  in  medicine,  but  yields  a 
larger  number  of  official  compounds 
than  any  other  element. 

Upon  a  therapeutic  basis,  the  fol- 
lowing classification  of  some  of  the 
sodium  compounds  may  be  made : — 

Caustics:  Soda,  and  soda  with  lime 

Purgatives:  Sodium  phosphate,  sodium 
sulphate,  and  potassium  and  sodium  tar- 

Systemic  antacids:  Sodium  acetate,  so- 
dium bicarbonate,  monohydrated  sodium 
carbonate,  sodium  citrate,  and  potassium 
and  sodium  tartrate. 

Diuretics:  Sodium  acetate,  sodium  ben- 
zoate,  sodium  bicarbonate,  monohydrated 
sodium  carbonate,  sodium  citrate,  and 
potassium  and  sodium  tartrate. 

Febrifuges:  Sodium  acetate,  sodium 
benzoate,  sodium  citrate,  and  sodium 

Antiseptics:  Sodium  benzoate,  sodium 
borate,  sodium  chlorate,  sodium  hypo- 
chlorite, sodium  phenolsulphonate,  and 
sodium  salicylate. 


— The  official  preparations  of  sodium 
are: — 

Sod  a  hydroxidnm,  U.  S.  P.  (sodium 
hydroxide  or  hydrate:  caustic  soda), 
rapidly  deliquescent,  and  acquiring  a 
coating  of  sodium  carbonate;  soluble 
in  1  part  of  water  and  freely  in  alcohol. 

Liquor  sodii  hydroxidi,  U.  S.  P. 
(solution  of  sodium  hydroxide),  of 
about  5  per  cent,  strength.  Dose,  10 
to  30  minims  (0.6  to  2  c.c). 

Liquor  soda  chlorinata,  U.  S.  P. 
(solution  of  chlorinated  soda;  Labar- 
raque's  solution),  an  aqueous  solution 
of  several  chlorine  compounds  of  so- 
dium, containing  at  least  2.4  per  cent. 
by  weight  of  available  chlorine.  Dose, 
10  to  30  minims  (0.6  to  2  c.c). 

Sodii  acetas,  U.  S.  P.  (sodium 
acetate),  soluble  in  1  part  of  water 
and  in  23  parts  of  alcohol.  Dose,  10 
to  30  grains  (0.6  to  2  Gm.). 

Sodii  arsenas,  U.  S.  P.  (sodium  ar- 
senate). Dose,  Yxo  grain  (0.006  Gm.). 
(See  Arsenic.) 

Sodii  arsenas  exsiccatus,  U.  S.  P. 
(dried  sodium  arsenate).  Dose,  %o 
grain  (0.003  Gm.).     (See  Arsenic.) 

Liquor  sodii  arscnatis,  U.  S.  P. 
(solution  of  sodium  arsenate).  Dose, 
3  minims  (0.2  c.c).     (See  Arsenic.) 

Sodii  henzoas,  U.  S.  P.  (sodium 
benzoate),  soluble  in  1.6  parts  of 
water  and  in  43  parts  of  alcohol.  Dose, 
10  to  20  grains  (0.6  to  1.3  Gm.).  (See 
i^ENzoic  Acid.) 

Sodii  bicarhonas,  U.  S.  P.  (sodium 
bicarbonate,  acid  sodium  carbonate, 
baking  soda),   soluble  in    12  parts  of 



water,  insoluble  in  alcohol ;  converted 
into  sodium  carbonate  on  boiling  its 
solution.  Dose,  10  to  60  grains  (0.6 
to  4  Gm.). 

Sodium  bicarbonate  should  only  be 
given  in  small  doses  (12  to  IS  grains 
— 0.75  to  1  Gm.)  several  times  daily. 
The  acidity  is  tlius  diminished  suffi- 
ciently to  reduce  the  pain,  yet  an 
increased  flow  of  acid  is  not  stimu- 
lated. It  has  been  proven  that  15  to 
45  grains  (1  to  3  Gm.)  given  before, 
during,  or  after  a  test-meal  will  favor 
the  passage  of  the  food  from  the 
stomach  into  the  intestines,  while 
larger  doses  may  cause  a  spasm. 
Even  if  the  drug  is  given  for  a  long 
time  in  the  doses  mentioned,  cachexia 
will  not  set  in.  The  fear  that  over- 
loading of  the  blood  with  sodium 
may  lead  to  increased  production  of 
hydrochloric  acid  is  very  remote.  E. 
Binet  (Progres  med.,  3,  1911). 

Trocliisci  sodii  bicarbonatis,  U.  S.  P. 
(troches  or  lozenges  of  sodium  bicar- 
bonate), each  containing  3  grains  (0.2 
Gm.)  of  the  bicarbonate  and  Vq  grain 
(0.01  Gm.)  of  nutmeg. 

Mistura  rhei  composita,  N.  F.  (mix- 
ture of  rhubarb  and  soda).  Dose,  2 
fluidrams   (8  c.c).     (See  Rhubarb.) 

Sodii  bisulphis,  U.  S.  P.  VIII 
(sodium  bisulphite;  acid  sodium  sul- 
phite; leucogen),  unpleasant  in  taste, 
gradually  oxidized  to  sulphate  on  ex- 
posure to  air,  soluble  in  3.5  parts  of 
water  and  in  70  parts  of  alcohol. 
Dose,  7y2  grains  (0.5  Gm.). 

Sodii  boras,  U.  S.  P.  (sodium  borate; 
borax),  soluble  in  20.4  parts  of  cold 
water,  in  0.5  part  of  boiling  water,  and 
in  1  part  of  glycerin,  with  which  it 
reacts  to  form  boroglyceride,  with  evo- 
lution of  gas ;  insoluble  in  alcohol. 
Dose,  yj/z  grains  (0.5  Gm.).  (See 
I!oRic  Acid.) 

Sodii  bromidum,  U.  vS.  P.  (sodium 
bromide).  Dose,  10  to  60  grains  (0.6 
to  4  Gm.).     (See  Bromine.) 


Sodii  carbonas  monohydratus,  U.  S.  P. 
(monohydrated  sodium  carbonate), 
containing  only  one  molecule  of  water 
of  crystallization,  and  therefore  nearly 
twice  as  strong  as  the  ordinary  soditmi 
carbonate ;  soluble  in  2.9  parts  of  water 
and  in  8  parts  of  glycerin,  insoluble  in 
alcohol.     Dose,  4  grains  (0.25  Gm.). 

Sodii  cyanidnm,  U.  S.  P.  (sodium 
cyanide),  deliquescent  and  smelling  of 
hydrocyanic  acid ;  freely  soluble. 

Sodii  glyccrophosplias,  U.  S.  P. 
(sodium  glycerophosphate),  saline  in 
taste ;  freely  soluble.  Dose,  4  grains 
(0.25   Gm.). 

Sodii  chloridum,  U.  S.  P.  (sodium 
chloride;  salt),  at  least  99  per  cent, 
pure,  soluble  in  2.8  parts  of  water, 
almost  insoluble  in  alcohol.  Dose,  as 
emetic,  4  drams  (16  Gm.). 

Sodii  citrus,  U.  S.  P.  (sodium  ci- 
trate), with  a  cooling,  saline  taste; 
soluble  in  1.1  parts  of  water,  slightly 
soluble  in  alcohol.  Dose,  10  to  60 
grains  (0.6  to  4  Gm.). 

Sodii  hypophosphis,  U.  S.  P.  (so- 
dium hypophosphite),  very  deliques- 
cent, soluble  in  1  part  of  water  and 
in  25  parts  of  alcohol.  Dose,  5  to  30 
grains  (0.3  to  2  Gm.).  (See  Phos- 
phoric Acid.) 

Syrupus  hypophosphitum,  U.  S.  P. 
(syrup  of  hypophosphites).  Dose,  1 
to  2  fluidrams  (4  to  8  c.c).  (See 
Phosphoric  Acid.) 

Sodii  indigotindisulphonas,  U.  S.  P. 
(indigo  carmine),  a  blue  powder  or 
purple  paste ;  sparingly  soluble  in 
water,  yielding  a  dark  blue  solution. 

Sodii  iodidum,  U.  S.  P.  (sodium 
iodide).  Dose,  5  to  60  (0.3  to  4  Gm.). 
(See  Iodine.) 

Sodii  nitras,  U.  S.  P.  VIII  (sodium 
nitrate;  Ghili  saltpeter;  cubic  niter), 
with  a  cooling,  saline,  slightly  bittei 
taste;  soluble  in  1.1  parts  of  water  and 

178                                                     SODIUM  (SAJOUS). 

in  about   100  parts  of  alcohol.     Dose,  cent  in  the   air;  soluble  in  2.8  parts 

5  to  15  grains  (0.3  to  1  Gm.).  of  water  and   in  glycerin,  insoluble  in 

Sod  a   nit  r  is,   U.    S.    P.    (sodium   ni-  alcohol.     Dose,  1  to  8  drams   (4  to  32 

trite).      Dose,    1    grain     (0.06    Gm.).  Gm.). 

(See  Nitrites.)  Sodii   sidpJiis    exsiccatus,    U.    S.    P. 

Sodii  phcnolsidphonas,  U.  S.  P.  (so-  (sodium  sulnhitcV  with  saline,  sulphur- 

dium    phenolsulphonate    or    sulphocar-  ous  taste ;  soluble  in  2  parts  of  water, 

bolate),   with   a    cooling,    saline,   bitter  sparingly  soluble  in  alcohol.     Dose,  15 

taste;  soluble  in  4.8  parts  of  water  and  grains   (1   Gm.). 

in  about   130  parts  of  alcohol.     Dose,  Sodii  thiosidpJias,  U.  S.  P.   (sodium 

4  grains  (0.25  Gm.),  thiosulphate   or   hyposulphite),   with   a 

Sodii   phosphas,    U.    S.    P.    (sodium  cooling,  afterward  bitter,  taste;  solu- 

phosphate;    disodium    hydrogen   ortho-  ble    in    about    0.35    part    of    water, 

phosphate),     efflorescent     in     the     air;  slightly    soluble    in    oil    of    turpentine, 

soluble  in  5.5  parts  of  water,  insoluble  insoluble  in  alcohol ;  the  aqueous  solu- 

in    alcohol;    an    aqueous    solution,    is  tion  is  rapidly  decomposed  by  boiling, 

slightly   alkaline   to   htmus.      Dose,   30  Dose,  5  to  20  grains  (0.3  to  1.25  Gm.). 

grains  to  4  drams  (2  to  15  Gm,).     (See  Potassii   et   sodii   tartras,    U.    S.    P. 

Phosphoric  Acid.)  (Rochelle  salt).     Dose,   1  to  8  drams 

Sodii  phosphas  cffervescens,  U,  S.  P.  (4  to  30  Gm.).     (See  Potassium.) 

(effervescent  sodium  phosphate),  con-  Among     the     sodium     preparations 

taining  20  per  cent,  of  exsiccated  so-  recognized  in  the  National  Formulary 

dium  phosphate,  together  with  sodium  are  the  following: — 

bicarbonate,    tartaric    acid,    and    citric  Soda  cum   cake,   N.   F,    (soda   with 

acid.      Dose,   2   to  8   drams    (8  to   30  lime;  London  paste),  a  paste  consist- 

Gm,),     (See  Phosphoric  Acid.)  ing  of  sodium  hydroxide  and  imslaked 

Sodii  phosphas  cxsiccatns,  U.   S.  P.  lime  in  equal  parts,  employed  as  escha- 

(dried   sodium   phosphate).     Dose,    15  rotic. 

grains  to  2  drams  (1  to  8  Gm.).     (See  Liquor  antisepticus  alkalinus,  N,  F. 

Phosphoric  Acid.)  (alkaline    antiseptic    solution,    contain- 

Sodii  perhoras,    U.    S.    P.     (sodium  ing,    among   other    substances,    sodium 

perborate)  ;   gives    off   9   per   cent,    of  borate,   sodium   benzoate,   and   oil   of 

oxygen   in   warm   or   moist   air;   white  gaultheria.     (See  Salicylic  Acid.) 

crystalline  granules  or  powder;  soluble  Liquor  sodii  arsenatis,  Pearson,  N.F. 

in  water.     Dose,  grain   (0.06  Gm.).  (Pearson's  solution).     (See  Arsenic.) 

Liquor  sodii  phosphatis  compositus,  Liquor  hypophosphitum,  N.  F,  (solu- 

U.  S,  P.  (compound  solution  of  sodium  tion     of     hypophosphites).      Dose,     1 

phosphate),  a  100  per  cent,  solution  of  fiuidram  (4  c.c).     To  replace  the  offi- 

sodium    (citro)    phosphate,    containing  cial    syrup    of    hypophosphites    when 

also    4    per    cent,    of    sodium    nitrate,  sugar  is  to  be  avoided. 

Dose,  ^  to  4  fluidrams.(2  to  16  c.c).  Liquor   hypophosphitum   compositus, 

Sodii    salicylas,    U.    S.    P.    (sodium  N.    F.    (compound    solution    of    hypo- 

salicylate).      Dose,    15    grains.       (See  phosphites).    Dose,  1  fluidram  (4  c.c). 

Salicylic  Acid.)  Liquor  sodii  boratis  compositus,  N.F. 

Sodii  sulphas,  U.  S.  P.   (sodium  sul-  (Dobell's  solution),  containing  phenol, 

phate;  glauber  salt),  rapidly  efflores-  0.3  per   cent.;   sodium  borate  and  bi- 



carbonate,  of  each,  1.5  per  cent.,  and 
glycerin,  3.5  per  cent.,  in  sterile  water. 

Liquor  sodii  carbolatus,  N.  F.  Ill 
(carbolated  soda  solution),  consisting 
of  phenol,  50  per  cent,  in  water,  to- 
gether with  sodium  hydroxide,  3.5  per 

Liquor  sodii  citratis,  N.  F.  (solution 
of  sodium  citrate;  potio  Riveri),  made 
from  citric  acid,  2  per  cent.,  and  so- 
dium bicarbonate,  2.5  per  cent.,  in 
water.     Dose,  2  fluidrams  (8  c.c). 

Liquor  sodii  citrotartratis  cffcrvcs- 
ccns,  N.  F.  (tartrocitric  lemonade). 
Dose,  12  flviidounces  (360  c.c). 

Liquor  sodii  oleatis,  N.  F.  Ill  (solu- 
tion of  soap). 

Elixir  sodii  hromidi,  N.  F.  (elixir  of 
sodium  bromide).  Dose,  2  fluidrams 
(8  c.c),  containing  20  grains  (1.3  Gm.) 
of  the  bromide. 

Elixir  sodii  hypophosphitis,  N.  F. 
(elixir  of  sodium  hypophosphite). 
Dose,  1  fluidram  (4  c.c). 

Elixir  sodii  salicylatis,  N.  F.  (elixir 
of  sodium  salicylate).  Dose,  1  fluidram 
(4  c.c).     (See  Salicylic  Acid.) 

Syrupus  bromidorum,  N.  F.  (syrup 
of  the  bromides).  Dose,  1  fluidram  (4 

Syrupus  calcii  et  sodii  hypophos- 
phitum,  N.  F.  (syrup  of  calcium  and 
sodium  hypophosphites).  Dose,  1  flui- 
dram (4  c.c). 

Syrupus  sodii  hypophosphitis,  N.  F. 
(syrup  of  sodium  hypophosphite). 
Dose,  1  fluidram  (4  c.c). 

Liquor  soda  et  nienthcc,  N.  F.  (soda 
mint  solution),  consisting  of  aromatic 
spirit  of  ammonia,  1  part ;  sodium  bi- 
carbonate, 5  parts,  in  spearmint-water, 
enough  to  make  100  .parts.  Dose,  2 
fluidrams   (8  c.c). 

Syrupus  hypophosphitum  composi- 
tns,  N.  F.  (compound  syrup  of  hypo- 
phosphites),  containing  hypophosphites, 

quinine,  and  strychnine.  Dose,  2 
fluidrams    (8  c.c). 

Sodii  borobcncoas,  N.  F.  (sodium 
borobenzoate),  a  mixture  of  sodium 
borate,  3  parts,  with  sodium  benzoate, 
4  parts.  Dose,  10  to  30  grains  (0.6  to 
2  Gm.). 

Sal  Carolinum  factitiiim,  N.  F.  (ar- 
tificial Carlsbad  salt),  an  amorphous 
powder  consisting  of  sodium  sulphate 
(dried),  18  parts;  sodium  bicarbonate, 
36  parts;  sodium  chloride,  18  parts, 
and  potassium  sulphate,  28  parts.  To 
be  dissolved  in  200  parts  of  water. 
Dose,  6  fluidounces  (200  c  c),  repre- 
senting an  equal  volume  of  Carlsbad 
water  (Sprudel).  If  the  crystalline 
preparation  of  the  same  nature  be  used, 
1.75  parts  of  the  salt  are  to  be  dis- 
solved in  200  parts  of  water. 

Sal  Kissingcnse  factitium,  N.  F. 
(artificial  Kissingen  salt),  consistmg  of 
sodium  chloride,  357  parts ;  sodium 
bicarbonate,  107  parts;  magnesium  sul- 
phate (anhydrous),  12  parts,  and 
potassium  chloride,  17  parts.  One  and 
a  half  parts  of  the  salt  are  to  be  dis- 
solved in  200  parts  of  water.  Dose, 
6  fluidounces,  representing  an  equal 
volume  of  Kissingen  water (Rakoczy). 

Sal  Vichy anum  factitium,  N.  F.  (ar- 
tificial Vichy  salt),  composed  of  so- 
dium bicarbonate,  846  parts ;  sodium 
chloride,  77  parts,  and  magnesium  sul- 
phate (anhydrous)  80  parts,  and  po- 
tassium carbonate,  38  parts.  To  be 
dissolved  in  200  parts  of  water.  Dose, 
6  fluidounces  (200  cc),  representing 
an  equal  volume  of  Vichy  water 
(Grande  Grille  spring). 

Pulvis  satis  Carolini  factitii  effcr- 
vcsccns,  N.  F.  (efi^ervescent  artificial 
Carlsbad  salt).  Dose,  90  grains  (6 
Gm.)  in  6  ounces  (200  c.c.)  of  water. 

Pulvis  salts  Kissingensis  factitii  ef- 
fervescens,   N.   F.    (effervescent   artifi- 



cial  Ki.vsmj^cii  .^.iii;.  lAJ^^c,  «S0  grains 
(5.5  (jm. )  in  6  Huidounces  (2(K)  cc.) 
of  water. 

f'ulri^  salis  I'ichyani  fiutitii  effer- 
vt:sctnui,  NT.  F.  (effervescent  artilicial 
Vichy  salt).  D<:>se,  57  grains  (3.75 
(im.)  in  6  rtuidouncea  (200  c.c.)  ot 

f'ldrif  .uiJui  i  u.nyam  j(U:tuii  effer- 
vcM<-its  cum  lithio,  M.  F.  (effervescent 
artificial  Vichy  .salt  witJi  lithium). 
Dose,  'X)  grains  {h  (Jm,),  repre.senting 
14  grains  (I  Gno,)  of  artificial  Vichy 
salt  and  5  grains  (0.,?  Gm,)  of  litliium 

Sofliunx  as  an  element  or  ion  exerts  in 
nio<lerate  amounts,  different  from  po 
tassium,  little  or  no  effect  upon  tJie 
ti.ssues  of  higher  animals.  That  the 
.sodium  ion  may  exert  a  deleteriiitJs  ac- 
tion on  s<jme  animal  cell,s  is  shown, 
htiwever,  l>y  tJie  (^  tlaat  .some 
ova  and  fish  ordinarily  inJiahiting  .sea- 
water  survive  longer  when  place<l  in 
distillerl  water  than  when  place^l  in  a 
solution  of  .«iodium  chioride  {."^i-itonic 
with  sea-water.  More  concentr.ntr  i 
.solutions  of  .soflirim  chloride,  in  ai;>.. 
tion  to  a  possible  ionic  poi>i(inous  ef- 
fect of  tJie  kind  descriJied  prcxluc; 
the  effects  characteristic  of  "salt  ac- 
tion" in  general,  viz.,  witJidrawal  of 
water  from  cells,  with  corresponding 
shrinkage  ai  the  latter  and,  where  the 
occasion  present^*,  effect-9  due  to  irrita- 
tion,  such  as  vomiting  in  the  case  of 
the  stfjmach. 

According  to  tiie  e:itpcriraents  of 
Miinch,  exhibition  for  a  few  days  of 
large  quantities  of  .sorlium  chloride  in 
man  causes  at  first  a  ^0n  decrea.'ie 
in  excretion  (especially  renal),  with  a 
corresponding  gain  of  body  weiebt ; 
after  a  time,  however,  the  excretions 
•    and    the     weiglit    decrcn 

Small  amount.>i  ol  .>alt  have  been  found 
at  times  to  les.^en  the  acidity  of  the 
ga.stric  juice,  but  the  greater  palatabil- 
ity  of  f<X)d  .sea.soned  with  salt  may 
counteract  this  by  augmenting  the  re- 
rtex  ga.stric  .secretion.  The  salivary 
How  is  increased  by  salt,  partly  tlirough 
reflex  action  and  partly  because  some 
of  it  is  excreted  by  tiie  .salivary  glands. 

.-Xhsorption  of  ins:;"ested  hypotonic 
.soluti<ins  of  .salt  takes  place  chiefiy 
fn^m  the  intchtine,  and  resultsi  in  a 
diluted  Condition  of  the  bloxl — hy<lre- 
mia — which  induces  diuresis.  The  flow 
of  urine  is  increased  more  by  direct 
.saline  infusion  into  Uie  bloo<i  than  by 
sahne  solution  (or  water)  absijrbcd 
fr<im  tJie  st<:)mach  and  b<:)web  Hyper- 
tonic salt  Si^lution  injected  into  the 
blo(xi  causes  marked  diuresis  tii rough 
absorption  of  water  from  the  bcwly  ti.s- 
sues,  hxst  hypertonic  salt  solution  in- 
gested causes  littie  or  no  diuresis,  as 
tht  salt  i,s  only  slowly  absorbed  from 
it,  and  though  tending,  for  a  time,  to 
increase  tiie  total  ludk  of  the  blood, 
does  not  render  it  hydremic. 

Sodium  kydroxidt:  (caustic  .sex la), 
like  potassium  hydroxide  and  calcium 
oxide,  is  a  .strong  caustic,  de.str<jying 
i4e  by  abstraction  of  water,  dissolu- 
tion of  albumin,  and  .saponification  of 
fats.  .Similar  effects  arc  produced  by 
liquor  sodii  hydroxidi  and  by  .scx^la  cnm 
calce  (N.  P.). 

Sodium  hypochionte,  official  \u  the 
liquor  sod^e  chlorinatjc  or  I^l:>arraquc's 
sM^lution,  gives  off  chlorine  and  pos- 
.sesses  the  anti.septic,  deodorant,  and 
bleaching  properties  of  tiie  latter.  It 
is  decidedly  irrit.ating  to  the  tissues, 
but  this  property  may  be  reduced, 
seemingly  without  loss  of  anti.septic 
power,  by  the  addition  of  sufficient 
Ixiric  acid  to  neutralize  the  free  alkali 
in  the  preparation. 




jikaljej  wtth.  the  veg^fcibte  vtciu^.  b> 
nt^ipjly  obijerbed  ami  oxiUiitKi  m.  tfee 
sy^ton  tx>  6?cni  soiiimir  ct" 
w-fickfit  tnsoreases  tire  al&almitry  . .  .  . 
btocti  irol  crtmt.  iimi  erases  limresij. 
Ov^r  dinict  ■'*::"-^uti  <>>£  ilkalrcce  ctr- 
bomttes  or  t '  —  -ittt^  suviiam:  :ic«tite 
xml  strnilar  salH  fctvi*  tfee  idv^nctge 
©f  not  netdn-  .  ice  gastnjc  jotoj. 

te^Bt  tx>  mocoos  nsatibntnies*  exerts  a: 
isQotfirag:  dfect..  ami  ttaais-  -  -  '  ■; 
thick  nmoiSv.    Tt  ts  cooMtv-  a'  -  ■- 

the  alfciTmitr  of  its  sofation^  c:  .:j.,<s 
oa  sranaiin^.  b«^ra-^"  "'"""  the  toss  of 
carbon,  dio-xide^    ,^  'n  dttote  sota- 

tHjtt  1s?>  Esotabfil  contractile  organs,  en- 
ctoJirrg-   vesijel-walls   ami   ciTirateil   eip-t- 
rftefimiL  Bt  canses  for  a  t 
tHate  altaBis^  cner^Esevi  actrvctr  anu. 
tooKitjr,  ami  ai  certani  p-  an: 

BBcreased  resfetance  te>  asfifevea   :••-," 
QXTg!e3i  exdnsiott:  liate-  -•- :  •  '^"- ■ 
activitT  c?  replaced  by    :.,..    ._-..-^>.\:. 
Expertmoits    ixt    dogs-    have    ??'' 
rirrtr  the  aQdhne  carbonates,   a 
tereti  tncemaltT.  (fe  not  trrliaen.ce  the 
race  €>£  gastrtc  secre:-    ■       They  temi. 
tQwever,  te  nacerease  gastric  motilrtv 
hf  ■vrtrtne  o€  the  carbon  '- 

T^Sfl  throc^  reacttott  wini  cae  iy  — ■- 
cMornr  acid  of  the  gastric  imce.  •"  " 
UE^  also  m  themselves-^  by  '-rr-.--.-  -^ 
:d%&t  local  trriratEoni..  esjsrt  j.  ..- jI 
cannmatrve  ettect.  rdieving-  gaseJtis 
lijtonioa  artti  the  consequent  pain. 
E^rvre  grains  i  Q.  J  Gm. )  <:JC  ^odnini  W.~ 
carbi-^nalK.  if  completely  utilized  in  the 
destnictaott  of  the  gastric  aciil  are 
c^abfe  QC  aetitrafizmg-  ab«:irt  154 
oraKes  o€  gastric  '   -.  ■        :. 

strength.    '^Trere  :  >:  ^-^ 

no  2ci'l.  as  tn  the  r^.:.:     ,  ^e- 

cweei  the  (^estijiJii  of  SUV     --  .  ^^ 

so&xEo.  biEaEfecajate  ampJy  tfissolves  the 

gastric   macas   ^soA   is   absocbe<l   mar- 
cfcxti^ied.    JfeotraJicitwii  t>f  .    - 

actid  has  been  hf' 

partly  or  cor. .       .        -     .    .        _     -.m- 

trie    hyperactdity .    Ltovrevxar,    it    "■^;-''' 

nevertheless*,  be  beieiiciaL  by  j 

excessive  irritatijon:  b-v  the  gastrtc  actd 

Ett    the     ■ 

catarrh  of  ciie  ;ai:i:ei\    :kv 

others  biive  -'        "  that   •  -  o^irt 

no  direct  •"■  —  th.e  -c^.,  •  ■••    "•* 

reactic-    ■  ■  ---^'^  -■- 

\fiew^   --  .  .-- ^ 

some,  sue  -.ire  e^'^re*^  'i  '■*■ 

tiaxatrve  etf ect.    Ottce  •    -  :  ■ : 

bloodL  so«  ■  carbonate  increases  the 

jf  the  tatter,  though  tts  r.- 

excrenott  readers  fit  tfiffrcttlt  ts*  ((jfecaiu 

a  lastitrg:  rescttt  bbb  t&cs  respect-      "^ 

of  che  ortEce  cs  redttced   ■ 

ir^'T-r^  """creased:  whe-- 

-      ij'cii    Clvch   t*;    — ^''er    ..  ^    ..  "  : 

■<i.   sodiora:    ._   .     •   'ate   tr^av"  b 

fee  it  arcchangeii 

Scilrttni  btcarfjorctte  alwtEjrs  strmtt- 
EEfees  t&e  gttstric  seci?etrotts^     Ehe  %>- 

tiT^,    _...-....-    iont«i    .„„^    ^._ ..        ■ 

so  tfett  t&ie  fuotf  cart  [©tve  t&ie  si 
acfti  birfbce-  Ifee  (ssKfissbre  ac&lfir?-  (it 
tfte  c&yme  '  L     T&e 

(ira^  ftits  a    ......j.^.   .    -  ■••£    '■'■- 

teJir  on.  tfce  fctniy  paiix  c:       - 
ever  m.   secretary   iaiSTrfEcxiaiiey-     im 
fr-  ■'•:^st  resTrfts-  ar^ 

Qi;  ..^.- .  -  .  -.  ^:  --:;i3nral  q£  twx? 
6;ottrs  before  tfee  nretr  for  a  i&se  of 
0:5  QiL-  {73  ^srams'i :  tixee  fcotrrs  for 
trwrnre  fefri-s  dose.,  lavf  foar  fcomrs  for 
I  •  ■  ■•  ■  ■'  -  "—  ~~  r— ■•ns-)..  Vf— ' 
sir;  ,  ev^Hi    •'    :  ■ 

tfee  nteaDs.  TBae  isrvx^  remfeirs  t&e 
stQniaid&:  content  alkaEiie  smS.  amdier 
tfre  stfimtttttiba  of  tMs  tEte  se    ■ 


cial  Kissingen  salt).     Dose,  80  grains  Small  amounts  of  salt  have  been  found 

(5.5  Gm.)   in  6  fluidounces   (200  c.c.)  at   times   to  lessen   the   acidity   of   the 

of  water.  gastric  juice,  but  the  greater  palatabil- 

Pulzns  salis  Vichyani  factitii  effer-  ity  of  food  seasoned  with  salt  may 
vescens,  N.  F.  (effervescent  artificial  counteract  this  Ijy  augmenting  the  re- 
Vichy  salt).  Dose,  57  grains  (3.75  flex  gastric  secretion.  The  salivary 
dm.)  in  6  fluidounces  (200  c.c.)  of  flow  is  increased  by  salt,  partly  through 
water.  reflex  action  and  partly  because  some 

Piilvis  salis    Vichyani  factitii  effer-  of  it  is  excreted  by  the  salivary  glands. 

vcsccns  cum  lithio,  N.  F.  (efifervescent  Absorption    of    ingested    hypotonic 

artificial     Vichy     salt     with     lithium),  solutions    of    salt    takes    place    chiefly 

Dos.e,  90  grains  (6  Gm.),  representing  from   the    intestine,    and    results    in   a 

14  grains  (1  Gm.)  of  artificial  Vichy  diluted  condition  of  the  blood — hydre- 

salt  and  5  grains  (0.3  Gm.)  of  lithium  mia — which  induces  diuresis.    The  flow 

citrate.  of   urine   is   increased  more   by   direct 

PHYSIOLOGICAL     ACTION.—  saline  infusion  into  the  blood  than  by 

Sodium  as  an  element  or  ion  exerts  in  saline    solution     (or    water)    absorbed 

moderate   amounts,  different   from  po-  from  the  stomach  and  bowel.     Hyper- 

tassium,    little    or   no   effect   upon    the  tonic    salt    solution    injected    into    the 

tissues    of    higher   animals.      That   the  blood  causes  marked  diuresis  through 

sodium  ion  may  exert  a  deleterious  ac-  absorption  of  water  from  the  body  tis- 

tion   on    some    animal    cells   is   shown,  sues,   but   hypertonic   salt   solution    in- 

however,  by  the  observation  that  some  gested  causes  little  or  no  diuresis,  as 

ova  and  fish  ordinarily  inhabiting  sea-  the  salt  is  only  slowly  absorbed  from 

water   survive   longer   when   placed   in  it,  and  though  tending,  for  a  time,  to 

distilled  water  than  when  placed  in  a  increase   the   total   bulk  of   the  blood, 

solution  of  sodium  chloride  isotonic  does  not  render  it  hydremic, 

with    sea-water.       More    concentrated  Sodium    hydroxide     (caustic    soda), 

solutions  of  sodium  chloride,  in  addi-  like  potassium  hydroxide  and  calcium 

tion  to  a  possible  ionic  poisonous   ef-  oxide,   is  a   strong  caustic,   destroying 

feet  of  the  kind  just  described  produce  tissue  by  abstraction  of  water,  dissolu- 

the   effects   characteristic   of    "salt   ac-  tion  of  albumin,  and  saponification  of 

tion"    in   general,    viz.,    withdrawal   of  fats.     Similar  effects  are  produced  by 

water   from   cells,   with    corresponding  liquor  sodii  hydroxidi  and  by  soda  cum 

shrinkage  of  the  latter  and,  where  the  calce  (N.  R). 

occasion  presents,  effects  due  to  irrita-         Sodium  hypochlorite,  official   in   the 

tion,  such  as  vomiting  in  the  case  of  liquor  sod?e  chlorinatse  or  Labarraque's 

the  stomach.  solution,    gives    off    chlorine    and    pos- 

According    to    the    experiments    of  sesse?    the    antiseptic,    deodorant,    and 

Miinch,  exhibition   for  a  few  days  of  bleaching  properties  of  the  latter.     It 

large  quantities  of   sodium  chloride  in  is    decidedly    irritating   to   the    tissues, 

man  causes  at  first  a   slight  decrease  but    this    property    may    be    reduced, 

in  excretion   (especially  renal),  with  a  seemingly    without    loss    of    antiseptic 

corresponding    gain    of    body    weight;  power,    by    the    addition    of    suf^cient 

after  a  time,  however,  the  excretions  boric  acid  to  neutralize  the  free  alkali 

-ncrease    and    the     weight     decreases,  in  the  preparation. 



Sodium  acetate,  like  other  salts  of 
alkalies  with  the  vegetable  acids,  is 
rapidly  absorbed  and  oxidized  in  the 
system  to  form  sodium  carbonate, 
which  increases  the  alkalinity  of  the 
blood  and  urine,  and  causes  diuresis. 
Over  direct  ingestion  of  alkaline  car- 
bonates or  bicarbonates,  sodium  acetate 
and  similar  salts  have  the  advantage 
of  not  neutrahzing  the  gastric  juice. 

Sodium  bicarbonate,  applied  in  solu- 
tion to  mucous  membranes,  exerts  a 
soothing  effect,  and  tends  to  dissolve 
thick  mucus.  It  is  mildly  alkaline,  but 
the  alkalinity  of  its  solutions  increases 
on  standing,  because  of  the  loss  of 
carbon  dioxide.  Applied  in  dilute  solu- 
tion to  isolated  contractile  organs,  in- 
cluding vessel-walls  and  ciliated  epi- 
thelium, it  causes  for  a  time,  like  other 
dilute  alkalies,  increased  activity  and 
tonicity,  and  in  certain  protozoa  an 
increased  resistance  to  asphyxia  from 
oxygen  exclusion;  later,  the  augmented 
activity  is  replaced  by  depression. 

Experiments  in  dogs  have  shown 
that  the  alkaline  carbonates,  adminis- 
tered internally,  do  not  influence  the 
rate  of  gastric  secretion.  They  tend, 
however,  to  increase  gastric  motility 
by  virtue  of  the  carbon  dioxide  liber- 
ated through  reaction  with  the  hydro- 
chloric acid  of  the  gastric  juice,  and 
may  also  in  themselves,  by  inducing 
slight  local  irritation,  exert  a  mild 
carminative  effect,  relieving  gaseous 
distention  and  the  consequent  pain. 
Five  grains  (0.3  Gm.)  of  sodium  bi- 
carbonate, if  completely  utilized  in  the 
destruction  of  the  gastric  acid,  are 
capable  of  neutralizing  about  1^ 
ounces  of  gastric  juice  of  0.3  per  cent, 
strength.  Where  the  stomach  contains 
no  acid,  as  in  the  resting  period  be- 
tween the  digestion  of  successive  meals, 
sodium  bicarbonate  simply  dissolves  the 

gastric  mucus  and  is  absorbed  un- 
changed. Neutralization  of  the  gastric 
acid  has  been  held  to  reduce  pancreatic 
secretion,  the  normal  stimulus  to  the 
pancreas  resulting  from  the  entrance 
of  acid  into  the  duodenum  having  been 
partly  or  completely  removed.  In  gas- 
tric hyperacidity,  however,  it  may, 
nevertheless,  be  beneficial  by  allaying 
excessive  irritation  by  the  gastric  acid 
in  the  duodenum,  thereby  relieving 
catarrh  of  the  latter.  Stadelmann  and 
others  have  shown  that  alkalies  exert 
no  direct  influence  on  the  secretion  or 
reaction  of  the  bile,  in  spite  of  former 
views  to  the  contrary.  According  to 
some,  sodium  bicarbonate  exerts  a  mild 
laxative  effect.  Once  absorbed  into  the 
blood,  sodium  bicarbonate  increases  the 
alkalinity  of  the  latter,  though  its  rapid 
excretion  renders  it  difficult  to  obtain 
a  lasting  result  in  this  respect.  The 
acidity  of  the  urine  is  reduced  and  its 
total  output  increased;  where  enough 
has  been  given  to  render  the  urine 
alkaline,  sodium  bicarbonate  may  be 
found  in  it  unchanged. 

Sodium  bicarbonate  always  stimu- 
lates the  gastric  secretions.  In  hy- 
perchlorhydria  it  should  be  given  in 
large  doses  some  time  after  meals, 
so  that  the  food  can  leave  the  stoin- 
ach  before  the  excessive  acidity  of 
the  chyme  has  been  restored.  The 
drug  has  a  remarkable  soothing  ac- 
tion on  the  tardy  pain  of  digestion, 
even  in  secretory  insufficiency.  In 
hypochlorhydria  the  best  results  are 
obtained  with  an  interval  of  two 
hours  before  the  meal  for  a  dose  of 
0.5  Gm.  (7.5  grains);  three  hours  for 
twice  this  dose,  and  four  hours  for 
a  dose  of  5  Gm.  (75  grains).  Very 
small  doses  can  be  given  even  with 
the  meals.  The  drug  renders  the 
stomach  content  alkaline,  and  under 
the  stimulation  of  this  the  secretions 
gradually  pour  out  to  neutralize  the 
alkalinity,  and  normal  acidity  is  thus 



acetic,  citric,  or  tartaric  acid,  which 
are  often  available  in  the  form  of 
vinegar,  or  lemon-juice.  Passage  of 
a  stomach-tube  is  dangerous,  as  it 
might  penetrate  the  corroded  gastric 

Olive  oil,  lard,  white  of  egg,  or 
milk,  should  be  given  as  demulcents. 
Morphine  may  be  given  to  alleviate 
the  pain.  Stimulants  may  be  re- 
quired to  combat  collapse ;  external 
heat  should  also  be  applied  under 
these  circumstances.  Later,  the  pas- 
sage of  bougies  or  surgical  proced- 
ures to  overcome  stenosis  may  be 

CARBONATE.— Sodium  bicarbonate 
is  free  of  caustic  action,  but  the  car- 
bonate may  corrode  tissues  when  ap- 
plied for  some  time  in  concentrated 
solution.  Giving  large  amounts  of 
the  alkaline  carbonates  and  bicar- 
bonates  to  animals  has  been  observed 
to  induce  a  chronic  gastroenteric  in- 
flammation, which  may  prove  fat-al. 

Sodium  bicarbonate  in  large  doses, 
such  as  300  grains  (20  Gm.)  or  more 
daily,  may  cause  an  increase  in  body 
weight,  due  to  retention  of  chlorides 
with  resultant  water  retention,  which 
may  go  on  to  the  appearance  of 
edema.  This  condition  is  most  likely 
to  appear  during  the  administration 
of  the  bicarbonate  to  cachectic  dia- 
betics with  acidosis,  but  it  can  be 
produced  in  an  experimental  way  in 
normal  individuals.  L.  A.  Levison 
(Jour.  Amer.  Med.  Assoc,  Jan.  23, 

SODIUM  CHLORIDE.  —  Serious 
symptoms  and  frequently  death  have 
resulted  from  the  introduction  of  a 
large  quantity  of  sodium  chloride  into 
the  system.  Such  poisoning  occurs 
oftenest  from  the  inadvertent  use  of 
a  strong  salt  solution  instead  of  nor- 
mal saline  solution  for  proctoclysis  or 

intravenous  infusion,  but  is  reported 
also  to  be  a  common  method  of  sui- 
cide in  one  of  the  provinces  of  China, 
a  pint  or  more  of  saturated  salt  solu- 
tion being  ingested  for  this  purpose. 
Combs  reported  a  fatal  case,  with 
crenation  of  the  erythrocytes  in  fresh 
blood,  in  a  woman  who  received  about 
4  ounces  (120  Gm.)  of  salt  in  a  strong 
solution  by  hypodermoclysis. 

The  symptoms  of  sodium  chloride 
poisoning  consist  of  nausea,  vomiting, 
diarrhea,  fever  up  to  104°  F.  (40°  C), 
delirium  or  coma,  and  fatal  collapse. 
In  cases  with  diminished  renal  per- 
meability and  salt  retention,  as  in 
nephritis  or  eclampsia,  even  normal 
saline  solution  may  increase  edema 
and  induce  edema  of  the  lungs,  or  the 
v^omiting  of  fluid  rich  in  chlorides 
(Bastedo).  Marked  edema  of  the 
legs  from  prolonged  use  of  large 
amounts  of  salt  with  the  meals  has 
also  been  reported. 

Case  of  a  healthy  boy  of  5  years 
who  received  an  injection  of  strong 
brine  as  a  domestic  remedy  for 
worms.  The  mother  made  the  mis- 
take of  putting  a  pound  instead  of 
a  tablespoonful  of  salt  in  a  quart  of 
water.  In  five  or  ten  minutes  the 
child  was  taken  with  pain  in  the 
head,  intense  thirst,  and  vomiting, 
soon  followed  by  severe  purging.  In 
thirty  minutes  he  had  become  un- 
conscious, and  one  convulsion  fol- 
lowed another  until  death  occurred 
five  hours  after  the  injection.  O.  H. 
Campbell  (Jour.  Amer.  Med.  Assoc. 
Oct.  5.  1912). 

SODIUM  NITRATE.  — The  ni- 
trates, in  excessive  amount,  especially 
if  taken  in  concentrated  form,  cause 
gastric  pain,  nausea,  vomiting,  and 
sometimes  diarrhea.  Blood  may  be 
eliminated  with  the  vomitus  and 
stools.  Either  diuresis  or  oliguria 
may    be    noted.      Further    symptoms 



are  motor  weakness,  mental  dullness, 
collapse,  and  .  coma,  terminating  in 
death.  Dilute  nitrate  solutions  may 
be  taken  in  large  amount  without 
trouble,  but  the  more  concentrated 
ones  induce  the  symptoms  referred  to. 

amounts  of  a  strong  solution  of  this 
salt  cause  repeated  alvine  discharges, 
which  finally  consist  chiefly  of  mu- 
cous fluid  stained  with  bile.  Serious 
poisoning  with  it  is  rare. 

THIOSULPHATE.— Although  large 
amounts  of  the  sulphites  have  been 
taken  by  man  without  the  production 
of  poisoning,  symptoms  or  irritation 
of  the  alimentary  tract  have  been 
noted  after  even  small  doses.  Some 
of  the  irritation  of  the  stomach  is  as- 
cribed to  the  liberation  of  sulphurous 
acid  by  the  hydrochloric  acid  of  the 
gastric  juice. 

THERAPEUTICS.  —  Gastrointes- 
tinal Disorders. — The  alkaline  salts  of 
sodium,  especially  the  bicarbonate, 
are  used  extensively  in  disorders  of 
the  alimentary  canal.  Given  in  the 
digestive  period,  the  bicarbonate  di- 
minishes the  secretion  of  gastric 
juice,  neutralizes  some  of  the  hydro- 
chloric acid,  and  acts  as  a  carmina- 
tive by  setting  free  carbon  dioxide. 
Where  organic  acids  are  present,  it 
may  likewise  neutralize  them,  and 
by  doing  so  lead  to  the  opening  of  a 
pylorus  previously  in  spasm. 

In  continuous  gastric  hyperacidity 
and  in  cases  witli  gastric  fermenta- 
tion and  resulting  "sick  headache," 
preparation  of  the  stomach  for  a  meal 
may  be  effected  by  giving  a  dose  of 
sodium  bicarbonate  an  hour  before  it. 
In  the  fermentation  cases  coml:)ina- 
tion  of  calomel  with  it  may  be  ad- 
vantageous.      For     hyperchlorhydria 

manifesting  itself  after  meals,  the 
drug  is  also  very  eft'ective,  and  is 
beneficial,  especially  when  taken  one 
to  two  hours  after  the  repast.  A 
combination  of  sodium  carbonate  and 
magnesium  oxide  may  be  even  more 
grateful,  the  latter  compound  exert- 
ing, in  addition,  a  local  sedative  ef- 
fect. Where,  however,  stimulation  of 
evacuation  is  particularly  desired,  an 
efl^ervescent  mixture  of  sodium  bi- 
carbonate, 30  grains  (2  Gm.),  with 
tartaric  acid,  10  grains  (0.6  Gm.)  — 
dissolved  separately  in  half  a  glass- 
ful of  water,  then  mixed — is  of  value. 
Such  a  mixture  may  also  prove 
useful  in  the  vomiting  attending 
acute  inflammatory  diseases  and  the 

The  early  morning  acidity  of  hy- 
peracid cases  may  be  prevented  by 
the  exhibition  of  a  dose  of  sodium 
bicarbonate  the  night  before.  Mucus 
may  be  removed  from  the  stomach, 
preparatory  to  breakfast,  by  a  dose 
taken  on  arising.  In  alcoholic  gas- 
tritis lavage  with  a  dilute  sodium  bi- 
carbonate solution  is  useful  for  the 
same  purpose. 

In  gastric  hyperacidity  alkalies 
have  two  indications.  They  may  be 
employed  in  the  late  pain  of  hyper- 
acidity, but  the  tendency  of  the  pa- 
tient toward  abuse  of  the  drug  must 
not  be  forgotten,  for  excessive  use 
may  cause  gastritis.  The  author  pre- 
fers bismuth  subnitrate  in  large  doses 
to  the  alkalies.  The  alkalies  may 
also  be  employed  to  hasten  the  di- 
gestive process;  here  the  so-called 
Vichy  cure  may  likewise  prove  bene- 
ficial. The  use  of  artificial  Carlsbad 
salt  seems,  however,  of  greater 
value,  the  results  being  more  last- 
ing. Hayem  (Tribune  med.,  xli,  281, 

The  prolonged  suppression  of  salt 
in  the  diet  reduces  pain  and  vomiting 
in   conditions    of   hyperacidity,    while 



in  other  conditions  in  which  the  HCl 
is  deficient  the  use  of  salt  increases 
it  and  aids  digestion  greatly.  The  au- 
thor's experiments  on  a  healthy  man, 
following  out  L.  Mcunicr's  technique, 
showed  that  with  certain  foods,  as 
meat,  the  digestion  was  the  same 
with  or  without  salt,  but  with  other 
foods,  such  as  milk,  eggs,  and  car- 
bohydrate foodstuffs,  the  digestion 
was  delayed  from  ten  to  twenty  min- 
utes when  no  salt  was  given  with 
them.  Thus,  in  certain  subjects  and 
with  certain  foodstuffs,  the  addition 
of  sodium  chloride  to  the  diet  favors 
the  gastric  secretion.  A.  Martinet 
(Presse  med.,  Apr.  1,  1908). 

In  children,  where  an  antacid  is  re- 
quired and  constipation  is  present, 
sodium  bicarbonate  is  preferable  to 

In  yeasty  vomiting,  especially  when 
sarcinse  are  present,  sodium  sulphite 
is  often  of  value  in  doses  of  from  5 
to  20  grains  (0.3  to  1.3  Gm.).  The 
vomiting  due  to  acid  fermentation  of 
starches  and  sugars  may  be  relieved 
by  the  same  salt  in  doses  of  from  20 
to  60  grains  (1.3  to  4  Gm.),  or  by 
sulphurous  acid,  in  doses  of  from  5 
to  60  minims  (0.3  to  3.6  c.c),  well 

In  cases  with  dyspeptic  pains  asso- 
ciated with  motor  insufficiency,  E. 
Binet  recommends  the  use  of  two  of 
the  following  powders  at  intervals, 
respectively,  of  one  hour  and  half  an 
hour  before  meals,  and,  if  necessary, 
at  the  same  intervals  afer  meals : — 

R  Sodii   bicarbonatis..  gr.  xij   (0.75  Gm.). 
Magnesii  oxidi  pon- 

derosi    gr.  iv  (0.25  Gm.). 

Pulveris  belladonH'CC 
folioruni  gr.  %   (0.01  Gm.). 

Pone  in  chartulam  no.  j. 

Where  there  is  pylorospasm  due  to 
hypersecretion,  a  powder  should  be 
taken  one  hour  after  the  meal  and  re- 

peated at  one  and  one-half-hour  inter- 
vals until  the  next  meal. 

In  duodenal  ulcer  sodium  bicar- 
bonate may  give  relief  when  the 
"hunger  pain"  appears. 

In  catarrhal  jaundice,  sodium  bicar- 
bonate, combined  with  rhubarb,  has 
been  considered  especially  useful. 
The  official  mixture  of  rhubarb  and 
soda  may  be  given. 

In  chronic  hepatic  affections  good 
results  have  at  times  followed  the  use 
of  the  solution  of  chlorinated  soda,  in 
doses  of  from  ^  to  2  drams  (2  to  8 
Gm.),  diluted  in  from  4  to  8  ounces 
(120  to  240  c.c.)  of  water.  . 

In  constipation  sodium  sulphate  is 
not  as  often  employed  as  some  other 
drugs  in  human  beings,  though 
largely  used  in  veterinary  practice,  as 
it  is  one  of  the  most  irritant  of  the 
saline  purges,  producing  large,  watery 
stools  with  considerable  griping.  The 
purgative  dose  is  from  ^  to  1  ounce 
(7>4  to  30  Gm.).  It  should  be  used 
with  some  caution  if  any  intestinal 
inflammation  be  present.  It  is  one  of 
the  constituents  of  Carlsbad,  Hun- 
yadi,  and  similar  waters.  According 
to  Maberly,  it  frequently  acts  as  an 
intestinal  antiseptic  in  small  doses. 

Sodium  sulphate  is  an  intestinal 
antiseptic.  After  observation  of  its 
action  in  dysentery  and  infantile  di- 
arrhea, the  writer  relies  almost  en- 
tirely on  it  in  all  septic  bowel 
complaints.  To  obtain  the  antiseptic 
action  one  must  avoid  doses  having 
an  aperient  action.  The  dose  should 
begin  with  about  6  grains  (0.4  Gm.) 
for  a  baby  under  6  months  of  age, 
increasing  up  to  1  dram  (4  Gm.)  for 
adults,  given  every  six  hours  in  one 
of  the  flavored  waters,  such  as  fen- 
nel. Children  over  6  months  old 
seldom  exhibit  any  aperient  effects 
from  doses  of  14  to  20  grains  (0.9  to 
1.3  Gm.).  The  writer  also  uses  the 
drug    in    typhoid    fever;    the    stools, 



from  being  loose  and  fetid,  become 
more  normal  in  appearance  and  odor, 
and  the  temperature  runs  a  lower 
course.  Maberly  (Lancet,  Nov.  10, 

For  diuretic  purposes,  4  Gm.  (1 
dram)  of  sodium  sulphate  may  be 
dissolved  in  1  or  V/2  liters  (quarts) 
of  v^rater,  to  be  divided  into  three 
doses,  one  in  the  early  morning,  on 
a  fasting  stomach;  one  in  the  fore- 
noon, and  one  in  the  afternoon ;  the 
water  must  be  sipped  slowly.  For  a 
light,  non-irritating  purgative  effect, 
5  Gm.  (V/i  drams)  of  the  salt  may 
be  dissolved  in  Yz  or  Y^  liter  (quart) 
of  water,  to  be  divided  in  two  doses, 
one  in  the  early  morning  and  one  an 
hour  before  the  noon  meal;  it  should 
be  taken  warm.  For  an  energetic 
purgative  action,  25  to  60  Gm.  (6  to 
15  drams)  of  sodium  sulphate  are  to 
be  dissolved  in  200  c.c.  (6  ounces) 
of  water,  sweetened  if  desired,  or 
flavored  with  lemon,  peppermint,  or 
anise-seed,  according  to  taste,  to  be 
taken  at  one  dose.  Alfred  Martinet 
(Presse  med.,  Aug.  23,  1911). 

Physiological  salt  solution  passes 
through  the  gastrointestinal  tract 
without  irritating  it  or  interfering 
with  osmotic  conditions.  There  is 
nothing  which  passes  along  so  rap- 
idly. The  writer  has  patients  drink 
2  glassfuls  of  a  0.9  per  cent,  solution 
of  sodium  chloride  twenty  minutes 
before  breakfast.  After  nine  or 
twelve  minutes  defecation  followed. 
The  stomach  expels  the  solution 
promptly,  and  reflexly  sets  up  peris- 
talsis throughout  the  intestinal  tract. 
The  larger  the  amount  ingested  the 
more  rapid  the  passage.  Most  min- 
eral waters  are  hypertonic  and  are 
absorbed  in  the  duodenum  unless 
large  quantities  are  taken.  After 
drinking  the  salt  solution  on  an 
empty  stomach  in  the  morning  the 
writer  has  the  patient  follow  it  with 
a  cup  of  coffee  or  other  appetizing 
drink.  In  atony  of  the  stomach,  the 
rapid  expulsion  of  the  physiological 
salt  solution  makes  it  a  valuable  reg- 
ulator of  the  bowels.  Best  (Med. 
Klinik,  July  27,  1913). 

The  use  of  sodium  citrate  has  been 
strongly  recommended  in  the  treat- 
ment of  digestive  disorders,  especially 
in  children,  as  well  as  in  acidosis  and 
in  pneumonia.  According  to  Lacheny, 
15  grains  (1  Gm.)  of  the  salt  allay 
dyspeptic  pain  in  the  stomach  and  23 
grains  (1.5  Gm.)  promptly  arrest  most 
attacks  of  vomiting. 

The  chief  uses  of  sodium  citrate 
in  infant  feeding  are  as  follows:  (1) 
for  weaning  the  healthy  infant;  (2) 
for  increasing  the  amount  of  milk 
taken  in  the  twenty-four  hours;  (3) 
for  correcting  milk  dyspepsia,  and 
(4)  for  the  avoidance  of  scurvy.  It 
is  not  antibacterial.  A  good  propor- 
tion is  1  grain  (0.065  Gm.)  of  sodium 
citrate  to  the  ounce  (30  c.c.)  of  milk. 
Poynton  (Brit.  Med.  Jour.,  Oct.  21, 

Good  results  obtained  from  the  use 
of  sodium  citrate  added  to  milk  in 
infant  feeding  when  gastric  disorders, 
especially  vomiting,  exist.  When  so- 
dium citrate  is  added  to  milk  the 
coagulum  is  less  solid  and  lighter. 
This  is  due  to  the  fact  that  in  the 
presence  of  sodium  citrate  the  cal- 
cium salts,  especially  the  chloride, 
which  augment  coagulation,  are  pre- 
cipitated. It  is  usual  to  administer 
1  to  2  Gm.  (15  to  30  grains)  a  day 
to  infants.  Vomiting  due  to  hypo- 
alimentation  may  derive  as  much 
benefit  from  its  use  as  that  due  to 
superalimentation.  The  drug  is  su- 
perior to  bicarbonate  of  sodium  in 
digestive  disturbances  in  adults,  and 
does  not  cause  a  secondary  secretion 
of  acid  in  the  stomach.  Variot 
(Tribune  med.,  Oct.,  1910). 

Sodium  citrate  facilitates  the  diges- 
tion of  milk  when  a  milk  diet  is  be- 
ing given,  preventing  the  formation 
of  large,  compact  clots  where  the 
fluid  is  drunk  too  quickly  or  in  ex- 
cessive amounts  at  one  time.  Many 
cases  of  infantile  dyspepsia  yield 
when  a  tablespoonful  of  a  10-grain 
(0.65  Gm.)  to  the  ounce  (30  c.c.) 
solution   of   sodium   citrate  is   added 



to  each  4-ounce  (120  c.c.)  bottle  of 

Sodium  citrate  also  acts  as  an  al- 
kali, is  soothing  in  pyrosis,  dimin- 
ishes gaseous  fermentation,  and  even 
obviates  the  regurgitation  of  food. 

Even  in  small  doses,  it  is  a  good 
laxative.  In  constipation  in  dyspep- 
tics it  lessens  autointoxication  and 
obviates  mechanical  disturbances.  In 
constipation  associated  with  hepatic 
congesion,  Huchard  frequently  ad- 
vised its  employment,  along  with 
sodium  sulphate  and  bicarbonate: — 

IJ  Sodii  citratis, 

Sodii  hicarhonatis, 

Sodii    sulphatis.. .  .aa.  3v   (40  Gm.). 

M.     Sig. :    One  teaspoonful  every  morn- 
ing in  a  hot  infusion. 
Plicque  (Bull,  med.,  May  31,  1913). 

In  certain  conditions  of  malnutri- 
tion, marasmus,  and  chronic  indiges- 
tion in  infants  and  children,  Le  Bou- 
tillier  and  others  have  recommended 
subcutaneous  injections  of  a  dilute 
sea-water  solution. 

In  applying  the  sea-water  treat- 
ment in  infants,  the  writer  followed 
the  Robert-Simon  method,  diluting  83 
parts  of  sea-water  with  190  parts  of 
pure  spring-water,  filtering  through 
a  germ-proof  Berkefeld  filter,  and 
putting  it  up  in  sterile  bottles.  The 
usual  injection  sites  were  just  below 
the  angle  of  the  scapula  or  in  the 
gluteal  regions,  the  former  being 
preferable.  The  amount  injected 
varied  from  10  to  60  c.c.  (2>4  drams 
to  2  ounces),  the  usual  dose  being 
15  to  30  c.c.  (^  to  1  ounce),  accord- 
ing to  age  and  urgency,  and  from 
three  times  a  week  to  every  day  for 
a  short  time.  Sometimes  five  or  six 
injections  improved  the  condition  so 
much  that  the  patient  was  discharged. 
In  other  cases  the  treatment  had  to 
be  kept  up  for  several  months.  There 
is  improvement  in  the  amount  of  food 
taken  within  the  first  two  or  three 
weeks;  this  is  noticeable  in  older 
children  suffering  from  malnutrition 
or    chronic    indigestion.      In    infants. 

distressing  colic  was  invariably  re- 
lieved within  the  first  two  weeks. 
The  skin,  often  harsh,  dry,  and  scaly, 
cleared  up  entirely,  whether  in  in- 
fants or  in  older  children.  The  pa- 
tients who  were  losing  weight  or 
stationary,  as  a  rule,  gained  after  the 
first  few  treatments,  sometimes  as 
much  as  an  ounce  a  day.  The  sleep 
of  many  patients  was  markedly  im- 
proved. The  treatment  is  a  useful 
adjunct  of  other  methods  in  the  mal- 
nutrition of  tuberculous  disease  "t 
that  following  any  of  the  infectious 
diseases,  T.  LeBoutillier  (Jour.  Amer. 
Med.  Assoc,  Jan.  1,  1910). 

In  the  cyclic  vomiting  of  children, 
rectal  or  oral  administration  of  a  2 
per  cent,  solution  of  sodium  bicar- 
bonate is  an  essential  measure  where 
■  acidosis  exists,  in  conjunction  with 
the  administration  of  dextrose,  seda- 
tion of  the  vomiting  reflex  by  means 
of  drugs,  and  exhibition  of  fluids  in 
copious  amounts. 

In  cancer  of  the  stomach  the  use  of 
sodium  chlorate  has,  in  some  cases, 
been  followed  by  good  results.  The 
initial  dose  recommended  by  Brissaud 
is  2  drams  (8  Gm.)  daily,  in  divided 
doses ;  this  is  gradually  increased  un- 
til 4  drams  (16  Gm.)  are  taken.  If 
albuminuria  be  present  or  develop, 
the  drug  is  contraindicated. 

In  mercurial  stomatitis,  aphthae, 
mucous  patches,  and  ulcers  of  the 
tonsils,  sodium  sulphite  in  1  to  8 
solution  may  be  applied  with  a  cot- 
ton pledget,  or  in  the  form  of  spray. 

Calomenopoulo  has  emphasized  the 
utility  of  sodium  chlorate  in  mercurial 
stomatitis.  He  also  noticed  that  so- 
dium chlorate  in  large  doses  reduced 
intolerance  to  potassium  iodide  where 
this  drug  was  being  taken  in  full 
doses  for  syphilis. 

Seatworms  {Oxyuris  vermicularis) 
may  be  dislodged  from  the  rectum  by 



injection  of  a  solution  of  the  chloride, 
and,  with  them,  the  intense  itching. 
The  injections  should  be  given  every 
morning,  then  every  two  to  four 
evenings,  with  the  buttocks  ele- 
vated or  in  the  Knee-chest  posture 
until  all  evidence  of  the  worms  has 

In  dysentery  the  use  of  sodium  ni- 
trate in  dram  (4  Gm.)  doses,  freely 
diluted,  every  three  hours,  has  been 

Cutaneous  Disorders. — In  acute 
eczema,  when  there  is  much  serous 
discharge,  the  following  application 
is  efficient:  Sodium  carbonate,  ^ 
dram  (2  Gm.)  ;  water,  1  pint  (500 
c.c).  The  solution  may  be  made 
stronger  in  old  cases  where  the  skin 
is  much  thickened.  When  the  weep- 
ing has  ceased  and  mere  desquama- 
tion remains,  the  alkali  ceases  toi  be 
of  use. 

The  pruritus  of  eczema,  lichen, 
urticaria,  dermatitis,  burns,  and  frost- 
bite may  be  relieved  by  applications 
of  the  following:  Sodium  bicarbonate, 
3  drams  (12  Gm.)  ;  glycerin  and  dis- 
tilled extract  of  witchhazel,  of  each, 
3  ounces  (90  c.c).  The  itching  of 
urticaria  and  lichen  will  often  yield 
to  a  1 :  100  solution  of  sodium  car- 
bonate, applied  with  a  sponge  or 

Poison-ivy  eruption  and  other 
forms  of  pruritus  may  be  similarly 
soothed  by  sodium  hyposulphite  in 
solution  (1  to  16),  a  solution  of  the 
bicarbonate,  or  by  the  solution  of 
chlorinated  soda,  diluted  1  to  32. 

In  parasitic  skin  diseases,  espe- 
cially those  due  to  the  tricophyton 
fungus,  as  pityriasis  versicolor,  the 
hyposulphite  (1  to  8)  in  solution  or 
ointment  is  valuable.  Startin  has 
recommended  the  following:    Sodium 

hyposulphite,  3  ounces  (90  Gm.)  ;  di- 
lute sulphurous  acid,  ^  ounce  (15 
c.c.)  ;  water,  enough  to  make  1  pint 
(500  c.c).  In  tinea  versicolor  and 
pruritus  vulvae  Fox  found  the  follow- 
ing useful :  Sodium  hyposulphite,  4 
drams  (16  Gm.)  ;  glycerin,  2  drams 
(8  Gm.)  ;  water,  enough  to  make  6 
ounces  (180  c.c). 

In  scabies  also  the  hyposulphite 
has  been  used  successfully.  After  the 
morning  bath  apply  the  hyposulphite 
in  solution  (1  to  1)  to  the  affected 
part  and  allow  it  to  dry  on  the  skin. 
At  night  bathe  with  the  following 
lotion,  which  may  be  diluted  if 
found  too  strong:  Dilute  hydrochloric 
acid,  4  ounces  (120  c.c)  ;  distilled 
water,  6  ounces  (180  c.c.)  (Ohmann- 

For  the  removal  of  freckles,  sun- 
bum,  and  tan  the  following  lotion 
may  be  used :  Sodium  chloride,  2 
drams  (8  Gm.)  ;  potassium  carbonate, 
3  drams  (12  Gm.) ;  rose-water,  8 
ounces  (240  c.c.) ;  orange-flower- 
water,  2  ounces  (60  c.c).  The  in- 
flammation of  sunburn  may  be  sub- 
dued by  applications  of  sodium  bicar- 
bonate in  solution. 

In  hyperidrosis  of  the  feet  and 
axillae  a  solution  of  the  carbonate 
freely  applied  locally  will  remove  the 
fetor  and  diminish  the  secretion  of 

In  burns  and  scalds  sodium  bicar- 
bonate in  powder  or  in  solution  re- 
lieves the  pain  and  soreness  very 
promptly.  It  may  also  be  applied 
with  advantage  to  insect  bites. 

The  carbonate  is  used  externally 
when  it  is  desirable  to  soften  or  re- 
move scaly  or  scabby  accumulations 
upon  the  skin,  as  in  certain  forms  of 
eczema,  plica  polonica,  etc. 

In  tuberculous  ulcers  and  in  psoria- 



sis,  g^ood  results  have  at  times  been 
secured  with  hypodermic  injections 
of  diluted  sca-ivatcr,  as  orijuinally 
su.G^n;-ested  by  Robert-Simon  and 

Genitourinary  Disorders.  —  Irrita- 
tion of  the  urinary  })assa£;;"es  due  to 
an  excess  of  acid  may  be  allayed  by 
sodium  bicarbonate  in  doses  of  10  to 
20  g-rains  (0.6  to  1.3  Gm.),  given  in 
a  glass  of  water,  every  four  hours. 

In  cystitis  a  1  per  cent,  solution  of 
the  bicarbonate  may  be  used  to  wash 
out  the  bladder  when  an  acid  condi- 
tion of  that  viscus  exists. 

Some  relief  is  afforded  in  gonorrhea 
by  injections  of  a  1  per  cent,  solution 
of  the  bicarbonate. 

In  malarial  hematuria  sodium  hy- 
posulphite is  given  with  advantage  in 
doses  of  from  10  to  30  grains  (0.6  to 
2.0  Gm.),  every  four  hours.  Its  mode 
of  action  is  unknown. 

Fischer's  solution,  containing  10 
Gm.  (150  grains)  of  sodium  car- 
bonate (crystallized)  and  14  Gm.  (210 
grains)  of  sodium  chloride  to  the  liter 
(quart)  of  water,  has  been  used  in- 
travenously in  amounts  up  to  2  liters 
(quarts)  for  the  relief  of  anuria  in 
scarlet  fever,  eclampsia,  Asiatic  chol- 
era, etc.  In  less  urgent  cases  of  im- 
paired renal  function,  including  cases 
of  chronic  nephritis,  the  sodium  bicar- 
bonate may  be  increased  to  15  to  30 
Gm.  (225  to  450  grains)  in  the  liter, 
and  the  solution  given  per  rectum  by 
the  drop  method. 

Sodium  chloride  having  long  been 
known  as  a  powerful  diuretic,  the 
writer  used  it  as  a  last  resort  in  ad- 
vanced nephritis,  and  obtained  striking 
benefit  after  a  prolonged  period  on  a 
salt-free  diet.  When  no  benefit  fol- 
lows the  salt-free  diet,  a  single  large 
amount  of  sodium  chloride,  1  to  3 
days    during    the    week,    may    induce 

marked  diuresis  and  considerable  clin- 
ical improvcnunt.  Polag  (Schweizer. 
mcd.  Woch.,  i,  29,  1920). 

Laryngologic  and  Respiratory  Dis- 
orders.— In  asthma  the  use  of  potas- 
sium nitrate  in  3-  or  4-  grain  (0.2  or 
0.26  Gm.)  doses  has  been  highly 
commended.  The  drug  is  probably, 
in  part,  changed  to  a  nitrite  in  the 
system,  and  acts  as  such. 

In  pulmonary  hemorrhage  the  ad- 
ministration of  dry  salt  is  a  popular 

Use  of  salt  by  the  mouth  or  in 
infusion  recommended  to  control 
hemorrhage.  Salt  enhances  the  co- 
agulating power  of  the  blood  in  the 
living  subject,  though  not  in  the  test- 
tube.  This  may  be  due  to  the  mobi- 
lization of  thrombokinase  stored  up 
in  the  tissues.  In  29  cases  of  hem- 
optysis the  writer  obtained  excellent 
results  by  giving  75  grains  (5  Gm.) 
of  sodium  chloride  by  the  mouth, 
coagulability  being  much  increased 
thereby  for  an  hour  to  an  hour  and 
a  half.  The  effects  become  evident 
in  a  few  minutes.  If  the  tendency 
to  hemorrhage  returns  later,  the  dose 
of  salt  is  repeated,  or  potassium  bro- 
mide substituted  in  the  dose  of  45 
grains  (3  Gm.),  the  bromide  having, 
further,  a  sedative  action.  In  the  most 
urgent  cases  the  use  of  sodium  chlo- 
ride and  potassium  bromide,  in  full 
doses,  may  be  combined.  R.  von  den 
Velden  (Deut.  med.  Woch.,  Feb.  4, 

In  capillary  hemorrhages,  including 
capillary  hemoptysis,  in  the  hemor- 
rhagic diathesis,  and  in  epistaxis  and 
metrorrhagia,  Reverdin  claims  2-grain 
(0.13  Gm.)  doses  of  sodium  sulphate 
every  hour  to  be  of  great  value.  The 
drug  must  be  given  by  mouth  or 
intravenously,  not  hypodermically. 
It  is  believed  by  him  to  increase  the 
coagulabilitv  of  the  blood. 

In  acute  tonsillitis,  catarrhal  condi- 
tions,  bronchitis,   etc.,   sodium   l)icar- 

SODIUM   (SAJOUS).  191 

bonate  in  solution  may  be  combined  Solutions  of  sodium  bicarbonate  are 

with  hamamelis,  belladonna,  or  other  extensively  used   in   catarrhal   condi- 

remedial  agent.     According  to  Bulk-  tions     to    soften     and     remove    dried 

ley,     coryza     may     be     successfully  secretions  and  thickened  mucus.    Do- 

treated    by    giving   20    to    30    grains  bclVs  solution  (sodium  bicarbonate  and 

(1.3  to  2  Gm.)   of  the  sodium  bicar-  borax,    of    each,    2    drams — 8    Gm. ; 

bonate  in  2  or  3  ounces  (60  or  90  c.c.)  phenol,  24  grains — 1.5  Gm. ;  glycerin, 

of  water,   every   half-hour,   for   three  14   drams — 56   Gm. ;   water,    1    pint — 

doses,   with   a   fourth   dose   an   hour  500  c.c.)  is  largely  used  for  this  pur- 

from    the    last    one.        Two    to    four  pose.    Pynchon  has  recommended  the 

hours  are  next  allowed  to  elapse,  and  following   as   better :    Sodium   bicar- 

the  four  doses  are  then   repeated   if  bonate  and  borax,  of  each,  2  ounces 

there  seems  to  be  necessity,  as  is  fre-  (60  Gm.)  ;  listerin    (liquor   antisepti- 

quently  the  case.    After  waiting  two  cus,  U.  S.  P.),  8  ounces    (240  c.c); 

to  four  hours  more  the  same  course  glycerin,  1^  pints  (750  c.c.)  ;  of  this 

may  be  taken  again.    To  be  promptly  add  1  ounce  (30  Gm.)  to  1  pint  (500 

effective  the  measure  should  be  begun  c.c.)  of  water. 

with  the  earliest  indications  of  coryza  Gynecological  and  Puerperal  Disor- 

and  sneezing,  when  it  rarely  fails  to  ders. — Leucorrhea,    when    dependent 

break  up  the  cold.  upon    an    increased    secretion    of    the 

K.    E.   Kellogg  points   out   that   in  cervical   glands,  frequently  yields   to 

hay    fever    marked    relief    from    the  injections  of  a  1  per  cent,  solution  of 

rhinitis  symptoms  follows  the  taking  the    bicarbonate.      This    secretion    is 

of  sodium  bicarbonate  in   1-dram   (4  strongly  alkaline,  and  is  checked  on 

Gm.)   doses  three  times  a  day.     The  the    general    principle    that    alkalies 

drug  appears  to  have  a  desensitizing  check  alkaline  secretions. 

action    on    the    mucous    membranes.  In  puerperal  metritis  the  solution 

In  a  few  cases  he  found  it  necessary  of  chlorinated  soda   (1  part  to   10  or 

to  supplement  the  treatment  with  a  12   of  water)    has   been   used   as   an 

nasal    spray    of    sodium    bicarbonate  antiseptic    injection.      In    the     same 

solution.  strength  it  may  be  used  as  a  vaginal 

In    affections    of    the    throat    and  douche    when    the    lochial    discharge 

fauces,    sodium    chlorate   is   a   better  becomes   fetid.      It   is   also   a   useful 

and  safer  remedy  than  the  potassium  injection    in    simple    and    gonorrheal 

salt.  vaginitis. 

In  malignant  forms  of  sore  throat  A  hypertonic  solution  of  4  drams 

and  in  diphtheria  the  official  solution  (16  Gm.)  of  sodium  chloride  and  >4 

^r  ^1,1^,-;,,^+    A        A^    rj/   A.     o  j^^^„  dram.    (2   Gm.)   of   sodium   citrate  to 

of  chlormated  soda  (%  to  2  drams —  ,        .       .r^r.        n      r                         i 

_        ^  ^           .                     .         r.  the    pint    (500   c.c.)    of   water   proved 

2  to  8  Gm.—m  water,  4  to  8  ounces—  ^^^    effective    vaginal    douche    in    all 

120   to   240   c.c.)    has   been   used   as   a  inflammatory  diseases  of  women  and 

gargle.      Sodium    sulphite   in   solutiotl  in    septic    conditions,    giving    better 

(1    to   8)    may    be    used    as   a   gargle,  results  than  the  customary  antiseptic 

spray,  or  local   application  in  similar  douches.      In    infected    puerperal    le- 

...              T     ,           ,       ,                   1  •  sions    of    the    genital    tract    healthy 

conditions.     It  has  also  been  used  in-  ,  ^.           „      ^^^„^^a    ;„    -,    f«,„ 

granulation    was    secured    in    a    tew 

ternally  in  combination  with  sulphur  ^ays.     After  clearing  out  the  uterus 

and  calomel.  in   puerperal   sepsis   and   douching  it 



with  the  hypertonic  saline  solution, 
a  few  tablets  of  salt  left  in  the  uter- 
ine cavity  cause  the  flooding  of  any 
remaining  organisms  with  the  serum 
drawn  out  to  dissolve  the  salt  and 
materially  hasten  recovery.  All  con- 
ditions producing  pelvic  congestion 
responded  well  to  the  hypertonic 
douches.  Enemata  of  water  contain- 
ing from  3  to  6  or  8  drams  (12  to  24 
or  32  Gm.)  of  salt  to  the  pint  (500 
c.c.)  proved  effective  in  emptying 
the  bowel  in  eclampsia  and  other 
conditions  requiring  a  watery  evacu- 
ation for  the  removal  of  toxic  ma- 
terial. Clifford  White  (Lancet,  Oct. 
30,  1915). 

Constitutional  Disorders.  —  Acute 
rheumatism,  though  usually  best 
treated  with  the  salicylates  (see 
Salicylic  Acid),  is  also  amenable  to 
the  action  of  the  alkalies.  Sodium 
bicarbonate  is  of  great  service  in 
allaying  the  pain  and  soreness  of  the 
joints  when  given  internally  in  doses 
of  from  15  to  30  grains  (1  to  2  Gm.) 
every  four  hours.  It  may  also  be 
used  in  solution  as  a  lotion,  applied 
around  the  joints  on  lint  or  cloths. 
Sodium  nitrate  in  solution  (1  to  3) 
has  been  used  externally  in  like  man- 
ner. Sodium  acetate  has  been  given 
in  acute  rehumatism  and  gout,  but  its 
value  is  less  than  that  of  the  corre- 
sponding potassium  salt. 

In  conditions  associated  with  acido- 
sis, including  diabetes  mellitus,  so- 
dium bicarbonate  or  carbonate  have 
been  extensively  used.  To  act  as  a 
blood  alkalinizer  sodium  bicarbonate 
should  be  given  shortly  before  meals, 
when  no  acid  to  neutralize  it  is  pres- 
ent in  the  stomach.  In  diabetic  coma, 
delayed  chloroform  poisoning,  and 
similar  severe  states  of  acidosis,  doses 
as  large  as  ^  ounce  (15  Gm.)  of 
the  bicarbonate  have  been  given  by 
mouth,  or  by  the  rectal  drop  method, 

amounts  up  to  1%  ounces  (50  Gm.) 
a  day,  in  a  3  per  cent,  solution  in 
water.  At  times,  gratifying  results 
have  been  obtained. 

Sodium  citrate  advocated  in  place 
of  sodium  bicarbonate  for  use  in 
acidosis.  It  is  practically  tasteless, 
and  may  be  added  to  the  food  or 
given  in  water  and  lemon-juice.  Al- 
though the  author  has  given  as  much 
as  l}/2  ounces  (45  Gm.)  a  day,  it 
causes  much  less  digestive  disturb- 
ance than  the  bicarbonate,  and  diar- 
rhea never  followed  its  administra- 
tion. Lichtwitz  (Therap.  Monat., 
XXV,  nu.  81,  1911). 

The  hypodermic  use  of  sodium  bi- 
carbonate solutions  has  fallen  into 
disrepute  on  account  of  their  ex- 
tremely irritating  properties.  This  is 
because  during  sterilization  this  salt 
is  largely  converted  into  sodium  car- 
bonate. The  latter  may  be  recon- 
verted into  sodium  bicarbonate  if 
carbonic  acid  gas  is  allowed  to 
bubble  through  the  sterilized  solu- 
tion. The  latter  is  then  well  borne 
both  subcutaneously  and  intraven- 
ously, and  is  indicated  in  diabetic 
coma.  A  4  per  cent,  solution  should 
be  used.  The  writer  advocates  the 
preparation  of  such  solutions  in 
sealed  flasks  with  a  carbonic  acid 
atmosphere.  Magnus-Levy  (Med. 
Klinik,  S.  2001,  1914). 

Vorschiitz  has  called  attention  to 
the  value  of  an  alkali  in  whipping  up 
the  body  cells  to  proper  metabolism 
and  elaboration  of  protective  sub- 
stances. A  deficiency  of  alkali,  he 
asserts,  may  be  responsible  for  defec- 
tive antibody  production.  In  cases 
with  severe  septic  processes,  osteo- 
myelitis, scarlatinal  nephritis  with 
abscess,  etc.,  he  witnessed  good  ef- 
fects from  having  the  patients  drink 
during  the  day  a  bottle  of  Seltzer- 
water,  in  which  150  to  300  grains  (10 
to  20  Gm.)  of  sodium  bicarbonate  had 
been   dissolved.      Although    in    some 



cases  gastric  discomfort  necessitated 
at  times  svispension  of  the  treatment 
for  a  day  or  two,  some  patients  took 
the  doses  mentioned  for  weeks  with- 
out disturbance,  and  all  cases  thus 
treated  recovered. 

Surgical  Disorders.  —  In  fractures 
and  sprains  a  solution  of  sodium  sili- 
cate constitutes  a  valuable  dressing, 
as  it  rapidly  becomes  hard  and  im- 
movable when  painted  over  the  band- 
ages and  thus  forms  an  immovable 
splint  which  is  cleaner  than  plaster 
of  Paris  and  equally  effective. 

Morbid  growths,  warts,  etc.,  may 
be  removed  by  applications  of  caustic 
soda  or  of  London  paste. 

Wright's  solution,  composed  of  4 
per  cent,  sodium  chloride  and  1  per 
cent,  sodium  citrate  in  water,  is 
useful    in    the    treatment   of   infected 

cold  more  of  the  hot  solution  is 
poured  over  the  whole  dressing.  The 
solution  is  contraindicated  if  there  is 
a  tendency  to  persistent  oozing  of 
blood  from  the  wound,  and  when 
protective  adhesions  are  desirable,  as 
in  certain  abdominal  wounds  just 
after  operation.  The  solution  should 
be  used  only  for  the  first  thirty-six 
to  seventy-two  hours  after  operation, 
during  the  acute  stage  of  the  mflam- 
mation.  If  used  longer  it  leads  to 
maceration  and  indolence  in  healing. 
L.  R.  G.  Crandon  (Annals  of  Surg., 
Oct.,  1910). 

Wright's  citrated  isotonic  solution 
(sodium  citrate,  0.5;  sodium  chloride, 
3.0;  distilled  water,  100)  used  with 
great  satisfaction  in  the  treatment 
of  wounds.  G.  K.  Dickinson  (Med. 
Rec,  June  20,  1914). 

Foul  ulcers,  sinuses,  etc.,  may  be 
cleansed  with  liquor  sodse  chlorinatae, 
diluted  in  the  proportion  of  ^   to  4 

wounds,  abscesses,  etc.  The  citrate,  drams  (2  to  16  c.c.)  to  8  ounces  (250 
by  precipitating  the  calcium  salts  in  c.c.)  of  water.  In  military  practice 
the  lymph,  prevents  coagulation  and  a  3^  per  cent,  solution  of  sodium  hy- 
insures  free  exit  of  lymph  discharge,  pochlorite  has  been  extensively  used 
The  chloride,  in  hypertonic  solution,  for  checking  infection  in  wounds, 
hastens  the  flow  of  lymph  by  osmosis,  Dakin's  solution  is  prepared  by  dis- 
thus  antagonizing  bacterial  develop-  solving,  in  10  liters  (quarts)  of  tap- 
ment,  and  is  itself  antiseptic  owing  to  water,  140  Gm.  (4^^  ounces)  of  dried 
its  hypertonicity.  sodium    carbonate    (or   400    Gm. — 13 

In     using    Wright's     solution     for     ounces — of  the   crystalline    salt)    and 
drainage,  the  abscess  is  opened  by  a      200  Gm.  (6%  ounces)  of  good  quality 

calcium  chloride.  The  mixture  is  well 
shaken  up  and  after  half  an  hour  the 
clear  liquid  separated  by  siphonage, 
filtered  through  cotton,  and  40  Gm. 
(1%  ounces)  of  boric  acid  added.  In 
Carrel's  technique  of  wound  treat- 
ment, rubber  tubes  surrounded  by  an 
absorbent,  spongy  material  are  car- 
ried to  the  bottom  of  the  wound  and 
in  each  of  its  recesses,  and  Dakin's 
solution  is  injected  into  the  tubes  at 
one  or  two-hour  intervals,  or,  better, 
introduced  by  continuous  instillation 
by  the  drop  method. 

wound  as  small  as  will  allow  the 
cavity  to  be  wiped  out,  or  thor- 
oughly emptied  by  expression.  The 
surrounding  skin  is  thoroughly 
cleaned  with  70  per  cent,  alcohol 
and  smeared  with  boric  acid  or 
eucalyptus  petrolatum.  If  the  skin 
tension  closes  the  lips  of  the  wound 
a  bit  of  rubber  dam  may  be  put  in. 
The  wound  is  covered  with  a  large 
pad  of  gauze  or  of  absorbent  cotton 
covered  with  gauze,  dripping  wet 
with  hot  salt  and  sodium  citrate 
solution.  The  part  is  put  at  rest. 
*  Outside  the  dressing  may  Ijc  applied 
a  hot  flaxseed  poultice  or  a  hot-water 
bottle.    As  often  as  the  dressing  gets 




Intravenous  infusion  of  3  to  5  c.c. 
(48  to  80  minims)  of  a  5  per  cent, 
salt  solution  practised  with  the  best 
results  before  operations  in  which 
parenchymatous  hemorrhage  is  feared 
or  when  the  blood  coagulates  less 
readily  than  normal.  The  measure 
is  advised  in  prophylaxis  or  during 
the  operation,  repeating  it  every  half- 
hour  as  needed.  Von  den  Velden 
(Zentralbl.  f.  Chir.,  May  21,  1910). 

Instruments,  especially  if  plated, 
when  boiled  in  a  solution  of  sodium 
carbonate  or  bicarbonate  come  out 
covered  with  a  white  scum,  are  slip- 
pery, and  less  quickly  dried,  and  are 
likely  to  turn  black,  especially  if  they 
have  any  blood  left  on  them.  The 
writer  recommends,  instead,  the  use 
of  sodium  hydroxide,  which  has  not 
these  disadvantages.  About  38  grains 
(2.5  Gm.)  or  Y^  inch  of  stick  caustic 
to  a  quart  (liter)  of  water  makes  the 
proper  solution.  I.  M.  Ileller  (Jour. 
Amer.  Med.  Assoc,  Aug.  26,  1911). 

CHLORIDES  IN  URINE.— These  con- 
sist chiefly  of  sodium  chloride,  with  a 
small  amount  of  potassium  and  ammonium 
chlorides.  The  healthy  adult  excretes 
from  10  to  16  grams  of  chlorides  in  24 
hours.  The  chlorides  are  increased  nor- 
mally, by  increased  ingestion  of  salt,  by 
al^undant  drinking  of  water,  and  by  active 
exercise;  abnormally,  in  the  first  few  days 
after  the  crisis  of  acute  febrile  diseases, 
gradually  increasing  as  the  disease  abates; 
in  diabetes  insipidus;  in  dropsy  after 
diuresis  has  set  in.  The  chlorides  are 
decreased  normally  during  repose;  abnor- 
mally, in  all  acute  febrile  conditions  (espe- 
cially with  serous  exudations)  up  to  the 
crisis,  when  they  may  disappear;  in  pneu- 
moniia  their  absence  always  indicates  a 
serious  condition;  in  diarrhea;  in  chronic 
conditions  with  impaired  digestion  and 
dropsy;  during  the  formation  of  large  exu- 
dations; in  acute  and  chronic  diseases  of 
the  kidnej'S  with  albuminuria;  in  chronic 
diseases.  A  decided  diminution  or  ab- 
sence of  chlorides  in  a  febrile  condition 
strongly  suggests  pneumonia. 

Test  for  Chlorides. — Place  2  drams  of 
urine  in  a  test-tube,  acidify  with  10  or  12 
drops  of  nitric  acid,  C.  P.,  and  carefully 
add     1     drop     of     silver     nitrate     solution 

(1  to  8).  If  the  amount  of  chlorides  be 
about  normal,  this  drop  will  form  a  whit- 
ish globule,  a  solid  white  ring  or  one  or 
more  compact,  whitish,  flocculent  lumps, 
and  will  settle  to  the  bottom.  If  the  chlo- 
rides are  diminished,  there  will  be  only 
some  cloudiness.  (Jne  may  use  a  speci- 
men of  normal  urine  in  another  test-tube 
as  control.  When  the  exact  quantity  of 
chlorides  is  desired,  one  must  resort  to 
quantitative  titration,  the  technique  of 
which  may  be  found  in  larger  treatises  on 

tion.— As  ordinarily  prepared,  "nor- 
mal" saline  solution  is  of  0.8  to  0.9 
per  cent,  strength.  For  the  prepara- 
tion of  a  sterile  solution  of  this  type, 
sterile  sodium  chloride  may  be  dis- 
solved in  sterile  water  in  the  ratio  of 
1  dram  (4  Gm.)  of  the  salt  to  1  pint 
(roughly  500  c.c.)  of  water;  or,  the 
solution  may  be  sterilized  after  the 
salt  has  been  dissolved.  The  solution 
should  then  be  filtered  into  flasks,  and 
these  plugged  with  non-absorbent  cot- 
ton and  sterilized  in  toto. 

Hypertonic  sodium  chloride  solu- 
tions are  at  times  used,  as  in  the 
hypertonic  saline  treatment  of  Asiatic 
cholera  devised  by  Rogers,  in  which 
1.2  or  1.6  per  cent,  solutions  of  the 
salt  are  employed.      (See  Cholera.) 

Physiological  Action  and  Uses. — 
Introduction  of  normal  saline  solu- 
tion into  the  system  may  be  of  value 
in  a  variety  of  ways.  In  hemorrhage 
and  in  depleted  states,  such  as  that 
arising  in  cholera,  it  is  of  assistance 
to  restore  the  blood  volume  to  nor- 
mal, thereby  not  only  favoring  better 
distribution  of  blood  to  the  periph- 
eral parts  of  the  body,  but  also  im- 
proving heart  action  by  allowing  the 
organ  to  contract  under  more  normal 
mechanical  conditions.  In  toxe.mic 
states,  saline  solution  is  of  value  to 
promote    renal    activity    and    therewith 



elimination  of  toxic  material.  Where 
the  blood-pressure  is  low,  a  small  sa- 
line infusion  containing  a  moderate 
amount  of  epinephrin  is  of  great 
value,  though  unless  the  administra- 
tion be  continued  the  effect  soon 
wears  off  through  filtration  of  the 
solution  from  the  vessels  into  the  tis- 
sues. (Large  saline  infusions  under 
these  conditions  merely  favor  the  pro- 
duction of  edema.)  Saline  infusions 
are  also  of  value  for  the  relief  of 

Absorption  of  saline  solution,  how- 
ever given,  is  generally  rapid.  In 
saline  hypodermoclysis  a  pint  of  solu- 
tion may  be  absorbed  within  ten  or 
fifteen  minutes,  though  at  times 
marked  circulatory  weakness  greatly 
delays  the  process.  After  hemor- 
rhage, especially  rapid  absorption  oc- 
curs from  the  bowel. 

Modes  of  Administration. — Among 
the  various  routes  available  are:  (1) 
the  rectal ;  (2)  the  subcutaneous ;  (3) 
the  intravenous ;  and  (4)  the  intra- 

(1)  Saline  enteroclysis  (proctocly- 
sis ;  rectal  infusion)  is  advantageous 
in  that  the  slight  pain  entailed  in  the 
insertion  of  a  needle  through  the  skin 
is  avoided,  and  that  the  use  of  a  sterile 
solution  is  not  necessary.  The  older 
method  of  applying  the  procedure 
consists  merely  in  passing  into  the 
rectum  a  pint  to  a  quart  of  saline  solu- 
tion at  110°  F.  through  a  small  cathe- 
ter, twenty  to  thirty  minutes  being  al- 
lowed for  its  entrance  into  the  bowel. 
The  measure  may  be  repeated  at  four- 
hour  intervals  as  long  as  the  necessity 
for  saline  administration  persists.  An 
improved  procedure  is  that  recom- 
mended by  John  B.  Murphy,  in  which 
precise  adjustment  of  the  flow  of 
saline     solution     to     the     absorptive 

power  of  the  bowel  is  sought.  An 
excellent  description  of  Murphy's 
technique  of  proctoclysis,  kindly 
furnished  us  bv  Dr.  Richard  L. 
Stoddard,  of  Rochester,  N.  Y.,  is 
subjoined : — 

Cleansing  enemas,  to  the  extent  of  emp- 
tying the  intestinal  tract  of  fecal  matter, 
are  necessary  before  beginning  the  proc- 
toclysis treatment.  Thorough  elimination 
of  all  formed  feces  from  the  intestinal 
tract  during  the  preoperative  preparation 
is  of  paramount  importance. 

The  saline  solution  is  made  by  adding 
1  dram  (4  Gm.)  each  of  sodium  chloride 
and  calcium  chloride  to  each  pint  (500  c.c) 
of  hot  water.  The  solution  must  be  main- 
tained at  a  temperature  per  rectum  of  100° 
to  110°  F. 

The  average  quantity  is  \y2  to  2  pint3 
(250  to  1000  c.c.)  every  two  hours.  The 
quantity  to  be  given  depends  upon  the 
severity  of  the  case,  the  age  of  the  pa- 
tient, and  the  development  of  an  edema. 
The  average  twenty-four-hour  quantity  is 
18  pints.  In  a  child  of  11  years  (a  patient 
of  Dr.  Murphy's)  30  pints  were  adminis- 
tered in  twenty-four  hours.  Murphy 
states  that  "less  than  8  pints  in  twenty- 
four  hours  is  of  very  little  value  from  a 
therapeutic  standpoint." 

The  base  of  the  saline  solution  container 
should  be  elevated  sufficiently — 2,  4,  or  6 
inches — above  the  buttocks  of  the  patient 
to  allow  1^  to  2  pints  of  the  solution  to 
flow  into  the  rectum  in  from  forty  to  sixty 
minutes.  The  rapidity  of  the  tlow  should 
never  be  controlled  by  the  use  of  forceps, 
clamps,  knots,  or  faucets,  in  connection 
with  the  tubing.  The  height  of  the  con- 
tainer must  always  control  the  hydrostatic 
pressure,  which  should  average  4  to  6 
inches,  and  not  exceed  15  inches. 

The  patient  is  placed  in  the  Fowler 
position,  and  the  proctoclysis  continued 
for  two  or  three  days,  and  sometimes  five 
or  six  days.  Too  much  solution  after  the 
third,  fourth,  or  fifth  day  is  indicated  by 
edema  of  the  ankles,  hands,  and  even  the 
face,  and  occasionally  i)y  threatened  heart- 
failure.  The  solution  should  then  be  dis- 
continued until  the  circulatory  equilibrium 
is   restored,    when   the   treatment   may    be 



repeated  if  indicated.  The  Fowler  posi- 
tion, being  uncomfortable  for  many  pa- 
tients, need  be  used  only  in  exceptional 
cases  where  abdominal  drainage  is  neces- 
sary for  twenty-four  to  forty-eighth  hourg. 
An  excellent  and  comfortable  substitute 
for  the  Fowler  position  is  to  raise  the 
head  of  the  bed  12  to  18  inches. 

A  medium-sized  hard-rubber  vaginal 
douche  tube,  with  several  %-  to  %-inch 
openings,  makes  a  useful  rectal  tube, 
which  must  be  flexed  at  an  obtuse  angle 
2  or  3  inches  from  its  tip.  The  rectal 
tube  will  cause  no  inconvenience  if  so 
strapped  to  the  thigh  as  not  to  press  on 
the  posterior  wall  of  the  rectum.  Fre- 
quent changing  of  the  rectal  tube,  as  re- 
moving and  inserting,  or  an  improper  posi- 
tion of  the  tube,  or  a  too  rapid  flow  of 
the  solution  into  the  rectum,  are  each  and 
all  very  annoying  to  the  patient,  and  soon 
produce  an  irritation  of  both  the  anus  and 
rectum,  resulting  in  partial  or  complete 
evacuation  of  the  saline  solution. 

When  the  patient  strains  during  the  act 
or  vomiting,  coughing,  or  sneezing,  or 
wishes  to  expel  gas  or  fluid,  provision 
should  always  be  made  for  a  sudden  re- 
turn of  the  fluid  through  the  rectal  tube 
and  rubber  tubing  into  the  saline  solution. 
For  this  important  purpose,  one  should 
use  a  medium-sized  rectal  tube  with  the 
openings  as  described;  avoid  attempting 
to  control  or  govern  the  rapidity  of  the 
flow  by  the  use  of  clamps  or  faucets, 
and  also  avoid  overdoing  the  hydrostatic 

If  the  rectum  is  not  in  an  irritated  con- 
dition from  surgical  interference,  or  other- 
wise, success  in  the  early  administration 
of  large  quantities  of  saline  solution  will 
be  had  with  the  above  technique. 

In  case  an  elaborate  and  electrically 
heated  solution  container  is  not  at  hand, 
an  ordinary  douche-can  may  be  employed, 
and  may  be  maintained  at  the  desired 
temperature  by  first  immersing  a  bath 
thermometer  in  the  saline  solution,  and 
then  surrounding  the  container  with  bot- 
tles filled  with  boiling  water,  or  immersing 
one  or  two  bottles  in  the  solution.  To 
further  retain  the  heat,  the  whole  ap- 
paratus, bottles  and  container,  may  be 
wrapped  in  a  warm  woolen  blanket.  By 
immersing  a  16-candle-power  electric-light 

globe  and  a  thermometer  in  the  saline 
solution,  the  desired  temperature  can  be 
more  easily  maintained. 

For  the  past  three  years  Dr.  Stod- 
dard has  been  using  the  Ny lander 
electric  saline  heater,  which  correctly 
regulates  the  temperature.  He  has 
thoroughly  tested  the  Murphy  method 
of  proctoclysis  in  peritonitis,  typhoid, 
uremia,  diphtheria,  pneumonia,  shock 
from  hemorrhage,  and  local  and  gen- 
eral septicemia,  and  has  found  it  of 
inestimable  value,  especially  if  used 
early  and  before  the  heart  has  been 
badly  affected  by  the  intoxication. 

In  lobar  pneumonia  proctoclysis 
with  hot  tap-water  was  usually  fol- 
lowed in  a  few  hours  by  abatement 
of  the  signs  of  toxemia  and  mental 
improvement.  In  typhoid  fever  bene- 
fit was  also  noted.  In  obstinate  cases 
of  delirium  tremens  the  mental  state 
rapidly  cleared  up.  In  4  cases  of 
scarlet  fever,  2  very  severe,  excellent 
results  were  obtained.  The  casts  and 
albumin  found  in  the  urine  early  in 
the  disease  disappeared  before  the 
patients  left  their  beds.  In  the  inter- 
current febrile,  "grippal"  attacks  of 
pulmonary  tuberculosis,  the  comfort 
of  the  patient  was  greatly  increased 
and  the  invasion  apparently  cut  short. 
In  the  sudden  flooding  of  the  sys- 
tem with  toxins  from  confined  pus 
which  not  rarely  occurs  in  tuber- 
culous subjects,  remarkable  ameliora- 
tion of  the  symptoms  may  follow 
saline  proctoclysis.  Henry  Sewall 
(Amer.  Jour.  Med.  Sci.,  Oct.,  1910). 

All  patients  show  less  rectal  irrita- 
tion to  proctoclj'sis  if  given  a  saline 
enema  before  the  operation.  Patients 
given  water  by  rectum  absorb  nearly 
400  c.c.  more  in  the  twenty-four 
hours  than  do  patients  given  salt 
solution,  the  average  for  the  former 
being  2444  c.c,  and  for  the  latter 
2041  c.c.  Patients  given  salt  solution 
by  rectum  require  nearly  twice  as 
much  water  by  mouth  to  relieve 
thirst — 696  c.c.  in  the  first  twenty- 
four  hours,  as  against  332  c.c.     The 



amount  of  urine  is  practically  the 
same  in  the  two  classes  of  cases.  In 
drainage  cases  more  fluid  may  be 
taken  by  rectum  than  in  laparotomies 
closed  without  drainage.  Proctocly- 
sis should  be  employed  more  fre- 
quently, and  in  all  classes  of  cases 
in  which  it  is  possible.  Care  should 
be  taken  to  prevent  "water-logging" 
of  the  system,  this  applying  to  both 
salt  and  water.  In  peritonitis  cases 
with  drainage,  the  patient  can  take 
four  or  five  times  as  much  fluid  by 
rectum  as  in  other  conditions.  H.  H. 
Trout  (Jour.  Amer.  Med.  Assoc, 
May  4,  1912). 

A  new  device  which  consists  in 
placing  a  two-quart  heating  bag  near 
the  patient's  rectum,  through  which 
the  salt  solution  pipe  passes  as  in  a 
hot-water  bath,  prevents  the  great 
loss  of  heat  from  the  tube,  as  in 
other  methods.  In  this  method  the 
temperature  of  the  saline  as  it  enters 
the  rectum  at  first,  when  the  heating 
bag  has  just  been  filled,  is  about  108° 
F.,  from  which  it  drops  gradually  in 
an  hour  and  a  half  to  98°,  when  the 
heating  bag  is  refilled  at  140°  F.  and 
the  rectal  temperature  returns  to 
108°  F.  G.  H.  Tuttle  (Inter.  Jour,  of 
Surg.,  June,  1913). 

Proctoclysis  method  applied  to  in- 
fants in  place  of  subcutaneous  saline 
injection.  Tolerance  was  perfect, 
even  in  the  youngest.  Fifty  or  100 
c.c.  of  isotonic  saline  solution  or  4 
per  cent,  solution  of  sugar  is  ab- 
sorbed as  rapidly  as  by  subcutaneous 
injection.  Excellent  results  obtained 
in  children  of  all  ages  with  gastro- 
enteritis, cyclic  vomiting,  acute  ali- 
mentary anaphylaxis,  and  typhoid 
fever.  In  some  cases  a  little  epi- 
nephrin  was  added.  The  latter  was 
more  effectual  by  rectum  than  by 
mouth.  Lesne  (Bull,  de  la  Soc.  de 
Pediat.,  Oct.,  1913). 

Saline  proctoclysis  by  the  drop 
method  gives  in  typhoid  fever  results 
as  good  as,  if  not  superior  to,  those 
of  the  cold-bath  treatment.  In  the 
lung  complications  of  typhoid  fever, 
dyspnea  is  relieved  and  the  physical 

signs  of  lung  condensation  caused  to 
disappear  by  the  measure.  Even  in 
acute,  frank  pneumonia,  the  proced- 
ure at  once  reduces  the  dyspnea  and 
liquefies  the  secretions.  The  heart  is 
quieted,  marked  diuresis  supervenes, 
and  the  crisis  ordinarily  occurs  on 
the  fifth  day,  though  the  physical 
signs  persist  a  few  days  longer.  P. 
E.  Weil  (Presse  med.,  Feb.  14,  1916). 

(2)  Saline  hypodermoclysis  (sub- 
cutaneous infusion),  while  usually 
highly  efficient,  is  somewhat  painful. 
Careful  asepsis  is  required,  and  care 
must  be  taken  not  to  introduce  too 
much  sokition  in  a  single  area,  lest 
the  prolonged  anemia  of  the  tissues 
lesuh  in  their  devitalization  and 
sloughing.  The  method  is  especially 
indicated  where  the  emergency  is  not 
such  as  to  require  intravenous  infu- 
sion but  the  rectal  route  is  unavail- 
able because  the  bowel  is  too  irritable 
or  for  some  other  reason. 

Hypodermoclysis  may  be  practised  un- 
der the  breast,  in  the  loose  tissue  over  the 
pectoral  muscle,  on  the  posterior  or  inner 
aspects  of  the  thighs,  beneath  the  ab- 
dominal skin,  including  the  iliolumbar 
regions,  or  between  the  scapulae.  The 
reservoir  for  the  solution  is  usually  of 
glass,  preferably  graduated.  The  needle 
should  be  long  and  preferably  of  a  large 
caliber,  such  as  1  to  2  millimeters,  for 
although  a  small  hypodermic  needle  may 
be  successfully  used,  greater  hydrostatic 
pressure  is  then  required  and  the  solution 
cools  more  as  it  descends  through  the 
tube,  necessitating  an  original  tempera- 
ture of  110°  C,  as  against  105°  C.  if  the 
aspirating  needle  is  used.  The  entire  ap- 
paratus should  have  been  sterilized.  Be- 
fore the  infusion  is  given,  the  breast,  in 
the  case  of  women,  is  carefully  disin- 
fected. It  is  then  raised,  and  the  needle, 
with  the  fluid  flowing  from  it,  gently  in- 
serted into  the  cellular  tissue  beneath  the 
organ.  The  pain  of  the  puncture  may  be 
avoided  with  ethyl  chloride.  Where  ele- 
vation of  the  reservoir  is  insufificient  to 
maintain  the  flow,  or  the  latter  stops  some 

1 98 


time  after,  withdrawing  the  needle  slightly 
or  rotating  it  will  usually  start  the  stream 
again.  If  not,  the  fluid  can  be  forced  in 
by  anointing  one  hand  and  the  tube  with 
petrolatum,  and  stripping  the  tube  down- 
ward between  the  lingsers.  Seven  hundred 
cubic  centimeters  of  fluid  (lyi  pints)  can 
be  injected  under  each  breast.  After  com- 
pletion of  the  procedure  the  puncture  can 
be  closed  with  rubber  tissue  or  adhesive 

Absorption  from  hypodermoclysis  where 
the  general  circulation  is  markedly  im- 
paired can  be  hastened  by  the  addition, 
where  possible,  of  enteroclysis,  or  even  a 
simple  hot  saline  enema  (R.  C.  Kemp). 
Gentle  local  massage  also  hastens  it. 

Salt  solution  for  therapeutic  pur- 
poses may  be  injected  into  the  pre- 
vesical space  of  Retzius.  This  space 
is  roomy,  the  connective  tissue  is 
loose,  and  can  easily  hold  one  liter 
(quart)  of  solution.  The  needle  is 
inserted  just  above  the  symphysis 
pubis,  and  pushed  along  the  rear  wall 
of  the  latter.  In  a  large  experience, 
puncture  of  the  bladder  never  oc- 
curred. The  author  uses  a  fairly 
large  needle.  One  is  thus  able  to 
inject  a  liter  of  solution  in  eight  to 
nine  minutes.  D.  Schoute  (Zentralbl. 
f.  Chir.,  July  6,  1912). 

For     hypodermoclysis     the     writer 
uses    a   large    silver    cannula   from    a 
Southey    tube    apparatus,    connected 
with  a  large  glass  funnnel  by  means 
of  a  tapered  glass  tube  and  a  section 
of  Southey's  rubber  tubing.     This  is 
all  readily  portable   and  readily   ster- 
ilized   by    boiling.      In    administering 
the   saline   the   anterior   axillary   fold 
is    grasped    firmly    and    drawn    out- 
ward.     The    trocar    with    cannula    is 
then  passed  into  the  skin  in  a  direc- 
tion   perpendicular   to   the   chest   and 
pushed   through   the  axillary   fold,   so 
that    its    point    emerges    within    the 
■  axilla.     The   trocar  is    then   removed 
and    the    cannula   is    pushed    outward 
until    its    shoulder    is    flush    with    the 
skin.     The   fluid   emerging  from   this 
cannula   squirts    in   all   directions.      It 
is   absorbed   so  rapidly  that  one  can 
inject    a    quart    into    the    tissues    in 

twenty  minutes  without  any  material 
swelling  occurring.  E.  M.  Wood- 
man  (Brit.  Med.  Jour.,  Feb.  8,  1913). 

(3)  Intravenous  saline  infusion  is 
indicated  in  the  more  urgent  emer- 
gencies, e.  g.,  after  very  abundant 
hemorrhage;  in  cases  of  shock;  where 
prompt  elimination  of  toxic  material 
from  the  blood  is  desired,  as  in  de- 
lirium tremens,  gas  poisoning,  and 
septicemia,  and  where  anuria  has  de- 
veloped, the  rise  in  blood-pressure 
attending  intravenous  infusion  caus- 
ing a  resumption  of  renal  function. 

The  apparatus  required  comprises  some 
.species    of    graduated    reservoir    for    the 
saline  solution,  a  connecting  rubber  tube 
with   pinchcock,   and   a   cannula  for  inser- 
tion   into    the    vessel.     A    slightly    curved 
cannula    is     to    be    preferred,    facilitating 
maintenance   in   the   lumen    of    the   vessel. 
In    emergencies    the    glass    portion    of    a 
medicine  dropper  may  be  substituted.     As 
in     hypodermoclysis,    the     apparatus     and 
solution  used  should  be  sterile.     The  nor- 
mal   saline    solution    should    be    placed    in 
the  reservoir  at  a  temperature  of  120°   F. 
Another   useful    form    of    apparatus    com- 
prises a  large  flask,  arranged  like  the  ordi- 
nary  wash    bottle,    with    two   glass    tubes, 
one  short  and  the  other  long,  entering  it 
through    the    stopper.      The    longer    glass 
tube,    dipping    into    the    contained    saline 
solution,  is   connected  by  tubing  with  the 
infusion   cannula,   while  to  the   other  tube 
a  rubber  pressure  bulb  is  attached.     Pres- 
sure   upon    this    bulb    forces    air    into    the 
flask,    and    hence    the    saline    solution   into 
the  vein.     The  temperature  of  the  solution 
in  the  flask  may  be  maintained  by  placing 
it    in    a    large    jar    partly    filled    with    hot 

Preparation  of  the  patient  consists  in 
placing  a  constricting  bandage  around  the 
upper  arm,  tightly  enough  to  obstruct  the 
venous  return  flow,  thus  distending  and 
rendering  easily  visible  the  vein  to  be 
employed,  usually  the  median  basilic  or 
median  cephalic  at  the  bend  of  the  elbow, 
applying  alcohol  or  tincture  of  iodine  at 
the  latter  area,  and  exposing  the  vein, 
under   aseptic   precautions,   for  a   distance 



of  about  one  inch.  After  passing  two 
ligatures,  untied,  round  the  vessel,  a  small 
valve-shaped  opening,  the  flap  of  vessel 
raised  pointing  distally,  is  made  v^^ith 
pointed  scissors,  and  the  cannula,  well 
filled  with  solution  and  free  of  air-bubbles, 
passed  into  the  opening.  The  cannula  is 
now  fixed  in  the  vessel  by  tying  the  upper 
ligature,  the  low  ligature  also  tied  to  close 
the  vein  below,  and  the  constricting  band 
round  the  arm  removed.  The  saline  solu- 
tion receptacle  should  be  at  such  an  alti- 
tude, usually  about  three  feet,  above  the 
vein  that  the  solution  will  run  in  but 
slowly.  The  heart  and  blood-pressure 
should  be  watched,  care  being  taken  not 
to  dilate  and  weaken  the  former  or  to 
raise  the  latter  excessively  by  infusing 
too  much  solution.  The  usual  amount  is 
1  to  3  pints  (500  to  1500  c.c).  In  shock 
injection  of  1:1000  epinephrin  solution 
with  a  hypodermic  syringe  into  the  lumen 
of  the  rubber  connecting  tube  may  be  ad- 
vantageous. This  should  be  done  slowly, 
a  few  drops  being  given  every  few  min- 
utes until  the  desired  rise  in  blood-pres- 
sure has  been  obtained.  Another  good 
procedure  is  to  drop  the  epinephrin,  ac- 
cording to  requirements,  in  a  funnel  into 
which  the  saline  solution  is  being  poured 
at  intervals  as  it  is  consumed. 

Many  users  of  intravenous  saline  ther- 
apy simplify  the  insertion  of  the  needle 
by  dispensing  with  exposure  of  the  vein, 
the  needle,  with  an  obtuse  angle  point, 
being  merely  thrust  obliquely  into  the 
distended  vessel  while  the  solution  is  flow- 
ing. The  point  of  the  needle  should  not 
be  too  sharp,  to  avoid  inadvertent  injury 
to  the  vessel's  walls  after  its  insertion, 
and  should  be  held  firmly  in  proper  rela- 
tion to  the  vein  while  the  saline  solution 
is  being  run  in. 

(4)  Intraperitoneal  saline  infusion 
is  of  value  at  the  termination  of 
abdominal  operations  attended  with 
marked  shock,  provided  extension  of 
an  intra-abdominal  infection  as  a  re- 
sult is  not  apprehended.  J.  G.  Clark 
found  that  flushing-  the  peritoneum 
with  the  solution  greatly  augmented 
leucocytosis,    and    advocates    its    use 

even  in  peritoneal  infections.  He 
makes  it  a  practice  to  leave  at  least  1 
liter  of  solution  in  the  peritoneal 
cavity  even  after  the  simplest  opera- 
tions, not  only  the  circulation,  but 
also  the  kidneys,  skin,  intestines,  and 
all  other  organs  functionating  better 
under  its  influence,  thirst  being  re- 
lieved, and  the  virulence  of  infection 
being  decreased. 

Contraindications.  —  Saline  infu- 
sions are  contraindicated  in  many  in- 
stances of  edema,  especially  where 
there  is  retention  of  sodium  chloride 
in  the  system  as  a  result  of  renal  im- 
pairment, and  in  pulmonary  edema. 
Pure  salt  solution  often  fails  to  bring 
on  diuresis  in  cholemic  states,  prob- 
ably because  of  a  prejudicial  action  of 
the  circulating  bile  on  the  kidneys. 

Other  Solutions. — The  studies  of 
Jacques  Loeb  have  shown  that  a 
solution  of  pure  sodium  chloride  in 
distilled  water  has  poisonous  proper- 
ties owing  to  the  complete  absence  of 
other  salts,  especially  those  of  calcium 
and  potassium.  As  the  tap-water  gen- 
erally employed  in  the  preparation  of 
normal  saline  solution  is  likely  to 
contain  some  calcium  salts,  but  little 
of  which  is  required  to  ofit'set  the 
poisonous  influence  of  the  sodium,  no 
difficulty  from  the  use  of  the  ordinary 
normal  saline  solution  is,  as  a  rule, 
experienced.  The  possibility  of  dan- 
ger from  excessive  displacement  by 
sodium  chloride  of  the  calcium  and 
potassium  salts  known  to  be  essential 
to  the  vitality  of  the  body  cells  is 
recognized,  and  Thies  has  advised 
against  the  use  of  pure  normal  so- 
dium chloride  solution,  especially  in 
small  children  with  disorders  asso- 
ciated with  a  considerable  elimination 
of  salts,  in  inanition  from  pyloric 
stenosis  or  other  cause,  in  cachexia, 



in  conditions  entailing  changes  in  the 
kidneys  or  cardiovascular  system,  and 
in  febrile  affections,  in  which  elimina- 
tion of  salts  other  than  those  of  so- 
dium is  augmented.  Thies  recom- 
mends for  rectal  introduction  a  solu- 
tion containing  0.6  per  cent,  of  sodium 
chloride  and  0.02  per  cent,  each  of 
calcium  chloride  and  potassium  chlo- 
ride, and  for  hypodermoclysis,  one 
containing  0.85  per  cent,  of  sodium 
chloride  and  0.03  per  cent,  each  of 
the  other  salts.  Among  other  im- 
proved substitutes  for  normal  sodium 
chloride  solution  are : — 

Dawson's  solution,  containing  0.8  per